COPYRIGHT. 1022
BY
K. A. DAVIS COMPANY
Copyrigbl, Ureal Urltaiii. All Rights Reserved
v/
PRINTED IN US. A.
PRESS OF
F. A. DAVIS COMPANY
PHILADELPHIA. PA.
CONTRIBUTORS TO VOLUME VIII.
W. WAYNE BABCOCK, A.M., M.D.,
Professor of Surgery, Temple University Medical School ; Surgeon in Chief
to the Samaritan and Garrctson Hospitals,
PurLADELPHIA, Pa.
REGINALD IT. SAYRE, M.D.,
Professor of Orthopedic Surgery, University and Eellevue Hospital Medical College,
New York City.
LEONARD FREEMAN, M.D.,
Professor of Surgery, University of Colorado School of Medicine,
Denver, Colo.
ERNEST LAPLACE, M.D., lA.A).,
Professor of Surgery, University of Pennsylvania Graduate Medical School,
Philadelphia, Pa.
HENRY T. BYFORD, M.D.,
Professor of Gynecology and Clinical Gynecology, University of
Illinois College of Medicine.
Chicago, III.
ALFRED C. WOOD, M.D.,
Assistant Professor of Surgery, University of Pennsylvania Medical School,
Philadelphia, Pa.
ANTHONY BASSLER, M.D.,
Clinical Professor of Medicine, New York Polyclinic Medical School,
Xew York City.
WM. BROADDUS PRITCHARD. M.D..
Professor of Neurology, New York Polyclinic Medical School,
New York City.
EDWARD JACKSON, M.D.,
Professor of Ophthalmology, University of Colorado School of Medicine,
Denver, Colo.
G. FRANK LYDSTON, M.D.,
Professor of Genitourinary Surgery, Illinois State University,
Chicago, III.
E. D. BONDURANT, M.D.,
Professor of Mental and Nervous Diseases, University of Alabama School of Medicine,
Mobile, Ala.
(iii)
iv COXTRIBUTORS TO VOLUME VIII.
H. BROOKER MILLS, M.D.,
Professor of Pediatrics, Temple University Medical School ; Visiting Physician
to the Philadelphia Hospital for Contagious Diseases,
Philadelphia, Pa.
MYER SOLIS-COHEN, M.D..
Visiting Physician to Home for Consumptives, Chestnut Hill, and Pediatrist
to Jewish Hospital and Eagleville Sanatorium for Consumptives,
Philadelphia, Pa.
J. MADISON TAYLOR, A.M., M.D.,
Professor of Physical Therapeutics, Temple University Medical School,
Philadelphia, Pa.
MARTIN E. REHFUSS, M.D.,
Associate in Gastrological Research, Chemical Department, and Instructor
in Medicine, Jeflferson Medical College,
Philadelphia, Pa.
A. ROBIN, M.D.,
Bacteriologist of the Wilmington City Water Department; formerly Pathologist and
Bacteriologist of the Delaware State Board of Health.
Wilmington, Del.
GUSTAVUS C. BIRD, M.D.,
Professor of Rontgenology and Radiotherapy, Temple University Medical School,
Philadelphia, Pa.
ANDREW F. CURRIER, M.D.,
Mt. Vernon, N. Y.
C. SUMNER WITHERSTINE, M.S., M.D.,
Lecturer on Pharmacology, Temple University Medical School,
Philadelphia, Pa.
F. LEVISON, M.D.,
Formerly Officer of Health,
Copenhagen, Denmark.
C. E. deM. SAJOUS, M.D., LL.D., Sc.D.,
Professor of Endocrinology in the University of Pennsylvania Graduate Medical
School and Professor of Therapeutics in Temple University Medical School,
Philadelphia, Pa.
L. T. deM. SAJOUS, B.S., M.D.,
Associate Professor of Pharmacolog>' in Temple University Medical School and Instructor
of Endocrinology in the University of Pennsylvania Graduate Medical School,
Philadelphia, Pa.
CONTENTS OF EIGHTH VOLUME.
PAGE
Rheumatism 1
Rheumatic Fever 1
Symptoms 1
Complications 3
Diagnosis 6
Secondary Infectious Arthritis .... 7
Acute Osteomyelitis 7
Gout 7
Etiology 7
Pathology 10
Prognosis 11
Treatment 12
Muscular Rheumatism 21
Symptoms 21
Etiology and Pathology 22
Treatment 2Z
Gonococcal (Gonorrheal) Rheumatism. 26
Symptoms 26
Diagnosis 27
Etiology 27
Prognosis 27
Treatment 27
Rheumatoid Arthritis. See Joints, Sur-
gical Diseases of.
Rhigolene. See Petroleum.
Rhinitis and Other Nasal Disorders. See
Index.
Rhubarb 29
Preparations and Doses 29
Poisoning by Rhubarb 30
Therapeutics 30
Rhus Poisoning. See Dermatitis Vene-
nata.
Ribs, Diseases and Injuries of. See Index.
Rickets. See Bones, Diseases of.
Riga's Disease. See Mouth, Lips, and
Jaws, Diseases of.
Riggs's Disease; Pyorrhea Alveolaris
(Spongy Gums) 30
Definition 30
Symptoms 30
Diagnosis 31
Etiology 31
Pathology 23
Treatment 33
Ringworm. See Trichophytosis.
Rochelle Salts. See Potassium and
Sodium Tartrate.
Rocky Mountain Spotted Fever (Tick
Fever) 35
Symptoms 36
Incubation 36
Fever 36
Circulation 36
Eruption Z7
Gastrointestinal Tract 27
Urinary Tract 37
PAGE
Rocky Mountain Spotted Fever (Tick
Fever), Symptoms {continued).
Respiratory Tract 27
Nervous System 27
Diagnosis 27
Etiology 38
Prognosis 38
Treatment 38
Rubella 39
Synonyms 39
Definition 39
Period of Incubation 39
Symptoms 40
Etiology 42
Complications and Sequelae 43
Prognosis 43
Treatment 43
Rubeola. See Measles.
Rue 43
Preparations and Doses 43
Physiological Action 44
Therapeutic Uses 44
Saccharin 44
Physiological Effects 44
Poisoning by Saccharin 45
Treatment of Poisoning 45
Therapeutic Uses 45
Salicylic Acid, The Salicylates, and
Salicin 45
Preparations and Dose 45
Unofficial Preparations 47
Incompatibilities 49
Modes of Administration 49
Contraindications 52
Physiological Action 52
Untoward EflFects and Poisoning 53
Treatment of Poisoning 54
Therapeutics 55
General Uses 55
Local Uses 58
Saline Infusion. See Infusions, Saline . 59
Salivary Glands, Diseases of 60
Xerostoma (Dry Mouth) 60
Symptoms 60
Etiology and Pathology 60
Treatment 60
Ptyalism '. 60
Treatment 60
Ptyalism 60
Salivary Calculus 60
Treatment 61
Tumors of the Salivarv Glands 61
Cvsts ". 61
Tumors of the Parotid 61
Tumors of the Maxillary Gland .... 61
Parotitis 62
Definitions 62
(v)
VI
CONTENTS.
PAGE
Salivary Glands, Diseases of, Parotitis
(coniiiiucd).
Traumatic Parotitis 62
Infectious Parotitis 62
1. Mumps 62
Incubation 63
Symptoms 63
Diagnosis 65
Etiology 65
Pathology 65
Complications and Sequelae . . 65
Prognosis 67
Treatment 67
2. Metastatic or Symptomatic Par-
otitis 68
Symptoms 68
Pathology 68
Prognosis 69
Treatment 69
Salol. See Salicylic Acid.
Salophen 69
Dose and Physiological Action 69
Therapeutics 69
Salpingitis. See Ovaries and Fallopian
Tubes, Diseases of.
Salt. See Sodium.
Salvarsan. See Dioxydiamidoarseno-
benzol.
Sandalwood and Oil of Sandalwood.... 70
Physiological Action and Dose 70
Therapeutics 70
Sanguinaria 70
Preparations and Doses 70
Physiological Action 71
Treatment of Poisoning 71
Therapeutic Action 71
Santonica and Santonin 71
Preparations and Doses 71
Physiological Action 71
Poisoning by Santonin 71
Therapeutic Uses 72
Sapremia. See Wounds, Septic, and
Sepsis.
Sarcoma. See Cancer.
Sarsaparilla 72
Preparations and Doses 72
Therapeutic Uses 72
Scabies 73
Definition 73
Symptoms 73
Etiology 73
Treatment 73
Scammonia 74
Preparations and Doses 74
Physiological Action 74
Therapeutic Uses 74
Scarlet Fever 75
Definition 75
Symptoms 75
Ordinary Tvpe 75
Mild Type " 77
Severe Type 78
Malignant Type 78
Surgical Scarlet Fever 79
Diagnosis and Etiology 79
Transmission 82
Period of Incubation 83
PAGE
Scarlet Fever, Diagnosis and Etiology
{roiitinued).
Period of Infection 84
Pathology 84
Complications and Sequelae 84
Angina 84
Otitis 85
Adenitis and Cellulitis 85
Joint Lesions 85
Nephritis 85
Pneumonia 86
Endocarditis and Pericarditis .... 86
Nervous Symptoms 86
Serous Membranous Involvement. 86
Superficial Gangrene 86
Prognosis 86
Prophylaxis 87
Treatment 89
Schlammfieber 94
Sciatica. See Nerves, Peripheral, Dis-
eases of.
Scleroderma 94
Definition 94
Varieties 94
Symptoms 94
Diagnosis 94
Etiology 95
Prognosis 95
Treatment 95
Sclerosis. See Index.
Scoliosis. See Spine, Diseases and In-
juries of.
Scoparius and Sparteine 95
Preparations and Doses 96
Physiological Action 96
Therapeutic Uses 97
Scopolamine (Hyoscine) and Scopola . . 98
Preparations and Dose 99
Incompatibilities 99
Modes of Administration 99
Physiological Action 99
Absorption and Elimination 100
Untoward Effects and Poisoning .... 100
Treatment of Poisoning 101
Therapeutics 102
As Sedative to the Central Nervous
System 102
As Mydriatic and Cycloplegic 103
Morphine-Scopolamine Anesthesia . . . 104
Morphine-Scopolamine Preliminary
to Inhalation Anesthesia . . 105
Morphine-Scopolamine Preliminary
to Local and Spinal Anal-
gesia 105
Morphine-Scopolamine in Obstetrics. 106
Scorbutus 108
Symptoms 108
Diagnosis 109
Etiology 109
Pathology 109
Prognosis 109
Treatment 109
Scorbutus, Infantile. See Infantile
Scorbutus.
Scrofula. See various forms of Tuber-
culosis.
CONTENTS.
Vll
PAGE
Scrofuloderma. See Tuberculosis of
the Skin.
Seasickness 1 10
Definition and Synonyms 110
Symptomatology 110
Complications and Sequelae Ill
Etiology Ill
Prognosis 113
Prophylaxis 113
Treatment 1 14
Senega 115
Preparations and Doses 115
Physiological Action 115
Therapeutic Uses 116
Sepsis, Septic Fever, Septic Infection,
Septic Poisoning, Septi-
cemia. See Wounds, Septic.
Septum, Diseases of. See Nose and
Nasopharynx, Diseases of.
Sera. See Diseases in which these are
used ; also Hematology.
Serpentaria 116
Preparations and Doses 117
Physiological Action 117
Therapeutic Uses 117
Shingles. See Herpes Zoster.
Shock 117
Definition 117
Symptoms 117
Delayed Shock 118
Shell Shock 118
Etiology and Pathology 119
Kinetic Theory 121
Prophylaxis 122
Anoci-Association 122
Treatment 124
Electrical Shock 127
Treatment 127
Silver 128
Preparations and Doses 128
Incompatibilities 130
Modes of Administration 130
Physiological Action 130
Poisoning " 132
Acute Poisoning 132
Treatment of Acute Poisoning .... 133
Chronic Poisoning 133
Treatment of Chronic Poisoning . . 134
Therapeutics 134
Gastrointestinal Disorders 134
Nervous Disorders 136
Surgical Disorders 136
Disorders of the Respiratory Tract 137
Ophthalmic Disorders 138
Cutaneous Disorders 139
Venereal Disorders 139
Removal of Silver Stains 140
'Sinuses, Nasal Accessory; Diseases of. 141
Maxillary Sinus or Antrum of High-
more 141
Inflammatory Disorders 141
Acute Inflammation 141
Chronic Infiammation or Em-
pyema 142
Treatment 143
Tumors of the Maxillary Sinus, or
Antrum 147
PAGE
Sinuses, Nasal Accessory, Diseases of.
Tumors of the Maxillary Sinus, or
Antrum (continued).
Polypi 147
Cysts 147
Osteoma 147
Malignant Tumors 148
Trea anent , 148
Frontal Sinus 148
Inflannnatory Disorders 148
Acute Inflammation 148
Chronic Inflammation 149
Treatment 149
Tumors of the Frontal Sinus 152
Mucocele 152
Cysts 153
Osteoma 153
Malignant Tumors 154
Treatment 154
Ethmoid Cells 154
Inflammatory Disorders 154
Acute Inflammation ; Acute Eth-
moiditis 154
Chronic Inflammation or Chronic
Ethmoiditis 155
Treatment 156
Tumors of the Ethmoidal Cells 158
Benign Tumors 158
Malignant Tumors 158
Treatment 158
Sphenoidal Sinus 159
Inflammatory Disorders 159
Acute Inflammation 159
Chronic Inflammation or Em-
pyema of the Sphenoidal
Sinus 159
Treatment 160
Tumors of the Sphenoidal Sinus 161
Benign Tumors 161
Malignant Tumors 161
Treatment 161
Skin-Grafting 161
Reverdin's Method 161
Thiersch's Method 162
Wolfe-Krause Method 163
Skin-periosteum Bone Grafts 163
Caterpillar Grafting 163
Tunnel Grafting 163
Subcutaneous Skin-Grafting 163
Anomalies in Grafting 163
Grafting from Dead Bodies 164
Sponge-Grafting 164
Grafting from Animals 164
Histology and Pathology 164
Comparison of Methods 164
Skin, Surgical Diseases of 165
Sebaceous Cysts, or Wens 165
Treatment 165
Furuncle 165
Diagnosis 165
Etiology 165
Treatment 165
Carbuncle 165
Doliiiition 165
Symptoms 166
Diagnosis 166
Etiology 166
Vlll
CONTENTS.
PAGE
Skin, Surgical Diseases of, Carbuncle
(continued).
Prognosis 166
Treatment 166
Keratosis Senilis 167
Prognosis 167
Treatment 167
Calvus ( Corn ) 167
Treatment 167
VerrucTe 168
treatment lf'8
Hypertrophicd Scars 168
Treatment 168
Keloid 168
Symptoms 168
Diagnosis , 169
Etiology and Pathology 169
Prognosis 169
Treatment 169
Malignant Degeneration of Scars . . 169
Burns 169
Definition 169
Varieties 169
Symptoms 170
'Local Effects 170
Electric and X-ray Burns 171
Burns of Mucous Surfaces 171
Constitutional Effects 1/1
Complications 172
Diagnosis 172
Medicolegal Aspects of Burns 172
Prognosis 173
Treatment 173
Constitutional 173
Local 174
Treatment of Electrical Burns . . . . 175
Scar Tissue Deformities 176
Sodium 176
Preparations and Doses 176
Physiological Action 180
Poisoning by Sodium and Its Salts . . 183
Sodium Hydroxide 183
Treatment of Poisoning by Sod-
ium Hydroxide 183
Sodium Bicarbonate and Carbonate . 184
Sodium Chloride 184
Sodium Nitrate 184
Sodium Sulphate 185
Sodium Sulphite and Thiosulphate . 185
Therapeutics 185
Gastrointestinal Disorders 185
Cutaneous Disorders 189
Genitourinary Disorders 190
Laryngological and Respiratory Dis-
orders 190
Gynecological and Puerperal Dis-
orders 191
Constitutional Disorders 192
Surgical Disorders 193
Chlorides in Urine 194
Saline Solution 194
Preparation 194
Physiological Action and Uses 194
Modes of Administration 195
(1 ) Saline Enteroclysis 195
(2) Saline Hypodermoclysis 197
(3) Intravenous Saline Infusion . 198
PAGE
Sodium, Saline Solution, Modes of Ad-
ministration (continued).
(4) Intraperitoneal Saline Infu-
sion 199
Contraindications 199
Other Solutions 199
Dawson's Solution 200
Locke's Solution 2(1)
Ringer-Locke Solution 200
Fleig's Solution 200
H. M. Adier's Solution 200
Fischer's Solution 200
Spigelia 200
Preparations and Doses 201
Physiological Action 20'
Poisoning by Spigelia 201
Therapeutic Uses 201
Spinal Anesthesia 201
Physiological Action 202
Technique 203
Solutions Used 203
Site of Injection 204
Syringe and Needle 205
Preliminary Narcotization 206
Associated Local Anesthesia 206
Induction and Management of Spinal
Anesthesia 206
After-treatment 208
Indications and Advantages of Spinal
Anesthesia 209
Contraindications 211
Technical Difficulties, Complications,
and Sequelae 212
Position af the Patient 212
Breaking of the Needle 212
Lack of Anesthesia 212
Dosage 212
Circulatory Depression 212
Respiratory Depression 213
Early After-effects 213
Nausea and Vomiting 213
Headache 213
Backache 213
Postoperative Pain 213
Albuminuria 214
Remote After-effects 214
Injury to Nervous Tissue 214
Neurotic Symptoms 214
Mortality . . .'. 214
Sacral Anesthesia 216
Spinal Cord, Diseases of 217
General Considerations 217
Infantile Paralysis; Polioencephalo-
myelitis 217
Synonyms 217
Definition 217
Symptoms 218
Poliomyelitic Form 220
Landry's Form 221
Bulbar Form 221
Encephalitic Form 221
Ataxic Form 221
Polyneuritic Form 221
Meningitic Form 221
Abortive Form 222
Diagnosis 222
Etiology 224
CONTENTS.
IX
PAGE
Spinal Cord, Diseases of, Infantile Pa-
ralysis, Polioencephalomyelitis (con-
tinued).
Pathology 225
Prognosis 225
Prophylaxis 226
Treatment 227
Operative Treatment 229
Tenotomy and Myotomy 230
Tendon Shortening 230
Tendon Lengthening 230
Tenodesis 230
Extra-articular Silk Ligaments . 230
Intra-articular Silk Ligaments . . 230
Arthrodesis 230
Articular Transposition 231
Astragalectomy 231
Nerve Anastomosis 231
Tendon Transplantation on Ten-
don 231
Tendon Transplantation to Peri-
osteum 231
Elongation of Short Tendons
by Means of Silk Sutures . . 231
Myelitis 231
Synonyms 231
Definition 231
Symptoms 232
Diagnosis -^^
Etiology 234
Pathology 235
Prognosis 236
Treatment 236
Amyotrophic Lateral Sclerosis 237
Definition 237
Symptoms 237
Diagnosis 238
Etiology 238
Pathology 238
Prognosis 239
Treatment 239
Primary Lateral Sclerosis 239
Synonyms 239
Definition 239
Symptoms 239
Diagnosis 240
Etiology 240
Pathology 240
Prognosis 240
Treatment 241
Landry's Paralysis 242
Synonyms 242
Definition 242
Symptoms 242
Diagnosis 243
Etiology 243
Pathology 244
Prognosis 244
Treatment ■ ■ 244
Hereditary Ataxia 245
Synonyms 245
Definition 245
Symptoms 245
Diagnosis 246
Etiology 246
Pathology 247
Prognosis 247
PAGE
Spinal Cord, Diseases of, Hereditary
Ataxia (continued).
Treatment 247
Ataxic Paraplegia 248
Synonyms 248
Definition 248
Symptoms 248
Diagnosis 248
Etiology 248
Pathology 249
Prognosis 249
Treatment 249
Syringomyelia 249
Definition 249
Symptoms 249
Diagnosis 251
Etiology 252
Pathology 252
Prognosis 253
Treatment 253
Spinal Cord and Nerves, Injuries and
Surgery of 254
Nerves, Injuries of 254
Subcutaneous Nerve Injuries 254
Concussion 254
Contusion 254
Pressure Paralysis 254
Stretching and Laceration 254
Displacement 255
Treatment 255
Open Nerve Injuries 256
Effects of Nerve Division 256
Process of Repair 256
Symptoms 257
Treatment 258
Nerve Suture or Neurorrhaphy 258
Neuroplasty 259
Nerve-grafting, Anastomosis, or
Implantation 260
Tubulization 260
Peripheral Nerve Injuries 261
Nerve Stretching or Neurectasy . . 263
Nerve Extraction or Avulsion .... 264
Neurectomy 264
Neurotomy 264
Removal of the Gasserian Gang-
lion or Its Sensory Roqt .... 265
Removal of the Cervical Sympa-
thetic 266
Spinal Meningitis. See Meningitis.
Spinal Paralvsis. Infantile. See Spinal
Cord: Infantile Paralysis
Spinal Paralysis, Spastic. See Spinal
Cord : Primary Lateral Scle-
rosis.
Spine, Diseases and Injuries of 266
Tuberculosis of the Spine (Pott's
Disease; Spondylitis) 266
Symptoms and Diagnosis 266
Etiology 269
Treatment 2()9
Plaster-of-Paris Jacket 271
Management of Abscess 273
b'orcilde i\eduction of Deformity . 274
Hibbs's Operation 274
Albee's Bone Grafts 275
X
CONTENTS.
PAGE
Spine, Diseases and Injuries of (con-
tinued).
Scoliosis, or Rotary Lateral Curva-
tures 275
Etiology 276
Diagnosis 276
Pathology 278
Treatment 279
Abbott's Method 280
Spondylitis Deformans ; Bechterew's
Disease 286
Symptoms 286
Treatment 286
Spinal Localization 286
Tumors of the Spinal Cord 287
Symptoms 287
Diagnosis 287
Treatment 287
Sacrococcygeal and Sacroanal Tumors. 287
Congenital Deformities of the Spine . . 290
Myelocele or Rachischisis 290
Spina Bifida 290
Prognosis 291
Treatment 291
Technique of Excision of the
Sac 291
Wounds and Injuries of the Spine . . 293
Gunshot and Punctured Wounds . . . 293
Meningomyelorrhaphy 294
Sprain and Dislocation 294
Symptoms 294
Dislocation of a Vertebra 295
Treatment 295
Bed-sores 295
Treatment 296
Sacroiliac Disease 296
Treatment 296
Disorders of the Coccyx 297
Coccygodynia 297
Laminectomy 297
Spine, Dislocation of. See Dislocations.
Spirillosis. See Relapsing Fever.
Spirit of Mindererus. See Ammonium.
Splanchnoptosis. See Intestines : Vis-
ceroptosis.
Spleen, Diseases of 298
Functions of the Spleen 298
Anomalies 299
Movable or Wandering Spleen 300
Symptoms 300
Diagnosis 301
Treatment 301
Acute Hyperemia or Congestive En-
larsrement of the Spleen .... 301
Symptoms 302
Treatment 302
Abscess of the Spleen or Acute Sup-
purative Splenitis 302
Symptoms 302
Treatment 303
Rupture of the Spleen 303
Symotoms 303
Treatment 304
Splenomegalv, or Chronic Enlarged
Spleen 304
Syphilitic Splenomegaly 304
Tuberculous Splenomegaly ■ 305
PAGE
Spleen, Diseases of, Splenomegaly, or
Chronic Enlarged Spleen (continued).
Malarial Splenomegaly (Ague
Cake) 305
Thrombotic Splenomegaly 305
Amyloid Spleen 306
Miscellaneous Forms of Spleno-
megaly 306
Treatment 308
Splenic Anemia 308
Symptoms 309
Diagnosis 310
Treatment 311
Gaucher's Splenomegaly 312
Symptoms 312
Treatment 313
Splenomegalic Polycythemia, or Ery-
thremia 313
Symptoms 313
Etiology and Pathology 314
Treatment 314
Perisplenitis : Capsulitis : Capsular
Splenitis 314
Symptoms 314
Treatment 315
Tumors of the Spleen 315
Symptoms 315
Treatment 316
Spleen, Injuries of. See Abdominal
Injuries .
Squill 316
Preparations and Doses 316
Phvsiological Action 317
Poisoning by Squill 317
Treatment of Poisoning 317
Therapeutic Uses 317
Squint. See Strabismus.
St. Anthony's Dance. See Chorea.
St. Anthony's Fire. See Erysipelas.
St. Vitus's Dance. See Chorea.
Staphylorrhaphy. See Surgical Ana-
plasty, or Plastic Surgery :
Cleft Palate.
Status Lymphaticus. See Thymus, Lym-
phaticus, and Mediastinum.
Diseases of.
Sterilization and Disinfection 318
Thermal Sterilization 318
Mechanical Sterilization 320
Chemical Sterilization 320
Practical Uses of Chemical Disin-
fectants 320
Disinfection of Surgeon's Hands. 320
Disinfection of the Operative
Field 321
Sterilization of Surgical Para-
phernalia 321
Disinfection of Bed and Body
Clothing 321
Disinfection of Bath Water 322
Disinfection of Feces, Urine, and
Sputum 322
Disinfection of the Sickroom 322
Disinfection of Passenger Cars . . . 323
Disinfection of Books 323
Stillingia 323
Preparations and Doses . . = 323
CONTENTS.
XI
PAGE
Stillingia (continued).
Physiological Action 323
Therapeutic Uses 324
Stokes-Adams Disease. See Heart and
Pericardium : Heart-block.
Stomach Cancer of 324
Etiology 324
Symptomatology and Diagnosis 324
Laboratory Diagnosis 326
X-ray Examination 328
Treatment 329
Stomach, Diseases of 330
Gastric Neuroses 330
Synonyms 330
General Considerations 330
Neurotic Secretory Conditions 330
Hyperacidity 330
Etiology 330
Symptoms 330
Diagnosis 331
Prognosis 331
Treatment 331
Subacidity and .\nacidity 333
Etiology 333
Symptoms 333
Diagnosis 333
Prognosis 333
Treatment 333
Heterochylia 335
Treatment 335
Gastromyxorrhea 335
Etiology 335
Symptoms 335
Diagnosis 335
Treatment 335
Neurotic Sensory Disturbances 336
Hyperesthesia Gastrica 336
Etiology 336
Symptoms 336
Diagnosis 336
Treatment 336
Gastralgia Nervosa 337
Etiology 337
Symptoms 337
Diagnosis 337
Treatment 337
Neurasthenia Gastrica 338
Polysymptomatic Neurosis or Nerv-
ous Dyspepsia 338
Etiology 338
Symptoms 338
Diagnosis 339
Prognosis 339
Treatment 339
Bulimia 340
Parorexia 34;)
Polyphagia 340
Akoria 341
Gastralgokcnosis 341
Anorexia Nervosa 341
Sitophobia 341
Disturbances of Gastric Motility 341
Myasthenia Gastrica and Gastric
Atony 341
Etiology 341
Symptoms and Diagnosis 342
Prognosis 343
PAGE
Stomach, Diseases of, Disturbances of
Gastric Motility, Myasthenia Gastrica
and Gastric Atony {continued).
Treatment 343
Secondary Gastric Dilatation 344
Etiology ■ 344
Symptoms 345
Diagnosis 345
Prognosis 346
Treatment 346
Acute Postoperative Dilatation of
the Stomach and Duo-
denum 346
Etiology 346
Symptoms and Diagnosis 346
Prognosis 347
Treatment 348
Gastropolyasthenia 349
Symptoms and Etiology 349
Diagnosis 350
Prognosis 350
Treatment 350
Cardiospasm 350
Etiology 350
Symptoms 351
Diagnosis 351
Prognosis 351
Treatment 351
Gastrospasm ( Pseudo Hour-glass
Contraction) 352
Diagnosis 352
Treatment 352
Pylorospasm 352
Etiology 352
Symptoms 352
Diagnosis 352
Treatment 352
Nervous Hypermotility 353
Etiology 353
Symptoms 353
Diagnosis 353
Prognosis 353
Treatment 353
Regurgitations 354
Symptoms 354
Prognosis 354
Treatment 354
Merycism 354
Symptoms 354
Treatment 354
Eructatio Nervosa (Aerophagia) .. 355
Symptoms 355
Diagnosis 355
Treatment 355
Singultus Gastrica Nervosa (Hic-
cough ) 355
Vomitus Nervosus 355
Varieties 355
Symptoms 356
liiagnosis 356
Treatment 356
Pneumatosis 357
Symptoms and Diagnosis 357
Treatment 357
Peristaltic Unrest 357
Symptoms 357
Diagnosis 357
Xll
CONTENTS.
PAGE
Stomach, Diseases of. Disturbances of
Gastric Motility, Peristaltic Unrest
(continued).
Treatment 357
Antiperistaltic Unrest, 358
Pyloric incontinence 358
Symptoms and Diagnosis 358
Treatment 358
Duodenal Regurgitation Due to I'"atty
Foods 358
Symptoms 358
Diagnosis 3^8
Treatment 359
Acute Gastritis 359
Acute Catarrhal Gastritis (Simple
Gastritis, Acute Indiges-
tion) 359
Etiology 359
Pathology 359
Symptoms 360
Diagnosis 360
Treatment 361
Acute Suppurative Gastritis (Phleg-
monous Gastritis, Gastric
Abscess ) 362
Etiology 362
Pathology 362
Symptoms 362
Diagnosis 363
Treatment 363
Infectious Gastritis 363
Toxic Gastritis 363
Etiology 363
Pathology 363
Symptoms 363
Diagnosis 364
Treatment 364
Antidotes 364
Chronic Gastritis 364
Varieties 364
Etiology 365
Pathology 365
Symptoms 366
Complications 367
Diagnosis 367
Gastric Neuroses 367
Gastric Ulcer 368
Gastric Cancer 368
Amyloid Degeneration of the
Stomach 368
Prognosis 368
Treatment 368
Surgical 373
Gastric and Duodenal Ulcer 373
Etiology 373
Pathology 373
Symptoms 374
Special Features of Duodenal
Ulcer 3/6
Diagnosis 377
Differential Diagnosis 378
Gastralgia 378
Carcinoma 378
Hyperchlorhydria and Gastrosuc-
corrhea 37S
Hemorrhagic and Other Forms of
Gastritis 379
PAGE
Stomach, Diseases of. Gastric and Duod-
enal Ulcer, Differential Diagnosis (con-
tinued).
Pylorospasm 379
Appendicitis 379
Hyperemesis of Pregnancy 380
Uremia 380
Biliary Conditions 380
Renal' Colic 380
Arteriosclerosis 381
Spinal and Other Diseases 381
Post-ulcer Conditions 381
Prognosis 381
Prophylaxis 382
Treatment 382
Diet 382
Medicinal Treatment 385
Special Treatment of Symptoms . 387
Sippy's Treatment 388
Surgical Treatment 388
Syphilis of the Stomach 391
Pathology 391
Symptoms and Diagnosis 391
Treatment 392
Tuberculosis of the Stomach 392
Etiology 392
Pathology 392
S3-mptoms and Diagnosis 393
Treatment 393
Pseudomembranous Gastritis 394
Benign Tumors of the Stomach 394
Pathology 394
Adenomata 394
Papillomata 394
Myomata and Fibromyomata .... 394
Lipomata 394
Myxomata 394
Lymphadenomata 394
Retention Cysts 395
Gastroliths and Foreign Bodies . . 395
Hypertrophy of the Pylorus 395
Symptoms and Diagnosis 395
Treatment 396
Stomach, Injuries and Surgical Diseases
of. See Abdomen. Surgery
of, and Abdominal Injuries.
Stomatitis. See Mouth, Diseases of.
Stovaine 396
Physiological Action 397
Poisoning 397
Therapeutics 397
Strabismus 398
Definition 398
Symptoms 398
Varieties 400
Diagnosis 401
Prognosis 493
Treatment ' 403
After-treatment 406
Stramonium 406
Preparations and Doses 406
Physiological Action 407
Therapeutic Uses 407
Strontium 407
Preparations and Doses 407
Physiological Action 407
Therapeutics 408
CONTENTS.
Xlll
'page
Strontium, Therapeutics (continued).
Acute Rheumatism and Constitu-
tional Disorders 408
Nephritis 408
Cardiovascular Disorders 409
Gastrointestinal Disorders 409
Nervous Disorders 409
Cutaneous Disorders 409
Strophanthus 409
Preparations and Doses 409
Physiological Action 410
Untoward Effects and Poisoning 411
Therapeutics 411
Struma. See Goiter.
Strychnine. See Nux Vomica.
Stye. See Eyelids, Diseases of : Hor-
deolum.
Stypticin. See Cotarnine.
Styptol. See Cotarnine.
Subphrenic Abscess. See Liver, Dis-
eases of.
Suggestion-therapy ; Psychotherapy ;
Hypnotherapy (Hypnotism). 414
Psychotherapy 414
Psychotherapeutic Technique 415
Hypnotherapy ("Hypnotism") 418
Technique 419
Therapeusis 420
Sulphonal 421
Modes of Administration 421
Physiological Action 422
Contraindications 422
Untoward Effects and Poisoning .... 422
Acute Sulphonal Poisoning 423
Treatment of Acute Sulphonal Pois-
oning 423
Chronic Sulphonal Poisoning 424
Treatment of Chronic Sulphonal
Poisoning 425
Therapeutics 425
Sulphur 426
Preparations and Doses 427
Physiological Action 427
Untoward Effects and Poisoning 428
Treatment 42<S
Therapeutics 428
Gastrointestinal and Constitutional
Disorders 428
Respiratory Disorders 429
Chlorosis 430
Cutaneous Disorders 430
As Insecticide 431
Sulphuric Acid 431
Preparations and Doses 431
Physiological Action 431
Treatment of Poisoning 431
Tlierapeutic Uses 432
Sulphurous Acid 432
Action and Uses 432
Sumbul 433
Preparations and Doses 433
Physiological Action 433
Therapeutic Uses 433
Sunstroke. See Heat Exhaustion.
Suprarenal Capsules. Duscases of. See
Adrenals, Diseases of.
PAGE
Suprarenal Organotherapy. See Animal
Extracts.
Surgical Anaplasty, or Plastic Surgery.. 433
General Considerations 433
General Technique 434
Deformities of the Lips 434
Varieties 434
Median Harelip 434
Simple Unilateral Harelio 434
Unilateral Harelip with Fissure
of the Bony Parts 434
Simple Bilateral Harelip 434
Complicated Bilateral Harelip .... 434
Treatment 435
After-treatment and Complica-
tions 435
Hypertrophy of the Lips 437
Deformities Due to Injury 437
Treatment 437
Everted Lip 437
Inverted Lip 438
Excision of Labial Cancers 438
Formation of the Lower Lip after
Complete Excision 438
Restoration of the Upper Lip 439
Macrostoma (Large Mouth ) 439
Treatment 439
Microstoma (Congenital Atresia Oris). 439
Treatment 439
Cleft Palate 439
Treatment 439
Staphylorrhaphy 440
Uranoplasty 440
After-treatment 441
Rhinoplasty 442
Indian Method 442
Italian Method 442
Reduction of Hump-nose (Aquiline
Nose) 443
Stenosis of the Nose 443
Paraffin Injections (Hydrocarbon Pro-
thesis) 443
Plastic Surgery of the Ear (Oto-
plasty) 443
Outstanding Ears 443
Abnormally Enlarged Ear (Macro-
tia) 444
Repair of Clefts and Fissure of the
Lobule 444
Enlarged Lobule 444
Elongated Lobule 444
Shortened Lobule 444
Adherent and Undeveloped L(jl)u!c . 444
.Sweat-glands, Diseases of the 444
Anhidrosis 444
Treatment 444
Hyperidrosis, or Excessive Sweatin.u . 445
Treatment 445
Bromidrosis 446
Treatment 446
Chromidrosis, or Colored Sweat 447
Treatment 448
Tumors of the Sweat-glands 448
Treatment ' 448
Svcosis. See Hair, Diseases of.
Syni])le])haron. .See Eyelids.
Synovitis. Sec Joints.
XIV
CONTENTS.
PAGE
Syphilis 44H
Etiology and Symptoms 448
Incubation Period of Syphilis 449
Specific Micro-organism of Syphilis. 449
Primary Local Changes 450
The Initial Lesion, or Chancre 452
Varieties of Induration 453
Diagnosis of Chancre 454
Loss of Tissue in Chancre 454
Secretion of Chancre 455
Comparative Frequency of Chancre
and Chancroid 455
Complications of Chancre 455
Mixed Chancre 456
Phagedenic Chancre 456
Infectious Secretions in Syphilis
and Infection 456
Modes of Contagion 457
Duration of Chancre 45(S
Number of Chancres 458
General Infection, Constitutional, or
Secondary Syphilis 458
Diagnosis 458
Constitutional Syphilis 458
Wassermann Test 458
Sources of Fallacy 458
General Adenopathy 459
The Roseola 459
Syphilitic Prodromes 459
Pharyngofaucial Infiltration 460
The Papular Syphilide 460
Syphilitic Alopecia 460
Syphilis of the Nails 460
Pustules, Vesicles, and Precocious
Skin-lesions 460
Special Mucous Lesions 460
Visceral involvement 461
Early Ocular Syphilis 461
Early Osseous Symptoms 461
Earlv Nerve Involvement in Syph-
ilis 461
Late Syphilis, Sequelar or So-called
Tertiary Syphilis 462
The Tubercular Syphilide (Gummy
Infiltration) 462
The Gumma 463
Late, or Sequelar, Nerve and
Brain Syphilis 463
Syphilides 464
Prognosis 465
Curability of Syphilis 466
When May a Syphilitic Marry? 466
Congenital Syphilis 466
Acquired Syphilis in Children 466
Syphilis Hereditaria Tarda 467
Lesions of Congenital Syphilis . . . 467
Treatment 468
New Remedies 471
Salvarsan 471
Method 473
Technique 473
Local Treatment of Chancre 473
Syringomyelia. See Spinal Cord, Dis-
eases of.
Tabes Dorsal is 474
Definition 474
PAGE
Talies Dorsalis (continued).
Varieties 474
Symptoms 475
Symptomatic Analysis 477
The Reflexes 477
Pupillary Symptoms 478
Optic Atrophy 479
Ocular-muscle Palsies 479
Ataxia 479
Tabetic Crises 480
Cardiac Crises 481
Sensory Symptoms 481
Trophic Symptoms 481
Vesical, Rectal, and Sexual
Symptoms 482
Special Senses 483
Diagnosis 483
Etiology 484
Pathology 486
Complications 488
Prognosis 488
Treatment 489
Tachycardia. See Heart : Frequent
Pulse.
Talipes. See Orthopedic Surgery.
Tamarind 496
Action and Uses 496
Tannic Acid 496
Preparations and Doses 497
Physiological Action 497
Therapeutic Uses 498
Tansy 499
Preparations and Doses 499
Physiological Action 499
Poisoning by Tansy 499
Treatment of Poisoning 499
Therapeutic LTses 499
Tape-worm. See Parasites, Disease Due
to.
Tar 499
Preparations and Doses 500
Physiological Action 500
Poisoning by Tar 500
Treatment 501
Therapeutics 501
AfYcctions of Mucous Membranes. 501
External Uses 501
Lysol 502
Poisoning by Lysol 502
Therapeutics 502
Pixol 503
Taraxacum 503
Preparations and Doses 503
Physiological Action 503
Therapeutic Uses 503
Tartar Emetic. See Antimony.
Telangiectasis. See Blood-vessels, Tum-
ors of.
Tendons, Bursse, and Fasciae, Diseases
of 504
Diseases of the Tendons 504
Acute Tenosynovitis 504
Symptoms 504
Palmar Abscess 504
Felon, or Whitlow 504
Treatment 504
CONTENTS.
XV
PAGE
Tendons, Bursae, and Fasciae, Diseases of,
Diseases of the Tendons (continued).
Chronic Tenosynovitis, or Thecitis.. 50^)
Treatment 505
Injuries of tendons. Displacement or
Dislocation 506
Treatment 507
Rupture 507
Treatment 507
Wounds of Tendons 507
Treatment 508
Diseases of the Bursse 503
Acute Bursitis 508
Treatment 508
Chronic Bursitis 508
Housemaid's Knee 509
Treatment 509
Bunion 509
Treatment 509
Ganglion 510
Treatment 510
Contraction of Tendons and Fascia . . 510
Dupuytren's Contracture 510
Treatment 510
Trigger-finger 511
Treatment 511
Tendon Transplantation 511
Tetanus 512
■ Synonyms • • 512
Definition 512
Symptoms 512
Diagnosis 514
Etiology 515
Bacteriology 517
Pathology 518
Prognosis 518
Treatment 519
Prophylaxis 525
Theobromine. See Diuretin.
Theocine 527
Physiological Action 527
Therapeutic Uses 527
Thermic Fever. See Heat Exhaustion
and Thermic Fever.
Thiocol 5?7
Preparations and Doses 528
Physiological Action 528
Therapeutic Uses 528
Thiosinamine 528
Physiological Action 528
Untoward Effects and Poisoning 529
Therapeutics 529
Thomsen's Disease. See Muscles : Myo-
tonia Congenita.
Thoracentesis. See Chest, Injuries and
Surgical Disorders of.
Thoracic Duct, Injuries of. See Chest,
Injuries and Surgical Dis-
orders of.
Thoracoplasty. See Chest, Injuries and
Surgical Disorders of.
Thoractomy. See Chest, Injuries and
Surgical Disorders of.
Thorax, Wounds and Injuries of. See
Chest, Injuries and Surgical
Disorders of.
Thorium. See X-rays and Padii'.ri.
PAGE
Thread-worms. See Parasites : Oxyuris
Vermicularis.
Thrombosis. See Vascular System, Sur-
gical Diseases of.
Thrush. See Mouth, Lips, and Jaws :
Parasitic Stomatitis.
Thymol 531
Physiological Action 531
Untoward Effects and Poisoning .... 532
Treatment of Thymol Poisoning . . . 532
Therapeutics 532
Internal and Systemic Uses 532
Local Uses 533
Thymus, Lymphatics, and Mediastinum,
Diseases of 533
Functions of the Thymus 533
Functions of the Lymphatics 533
Anomalies of the Thymus and Lym-
phatics 534
Diseases of the Thymus 534
Enlargement of the Thymus and
Lymphatics 535
Status Thymicolymphaticus 535
Symptoms 535
Thymic Stridor 535
Thymic xA.sthma 535
Thymic Death 535
Thymic Symptoms 536
Lymphatic Symptoms 537
Pathogenesis 538
Treatment 538
Thymectomy Technique 539
Prevention of Paroxysms 540
Diseases of the Lymphatics 540
Lymphadenitis 540
Lymphangitis 541
Symptoms 541
Diagnosis 541
Etiology 542
Treatment 542
Lymphangiectasia ; Lymphangioma . 542
Symptoms 543
Etiology 543
Treatment 544
Tumors of the Lympliatic System . . 544
Treatment 544
Glandular Fever 545
Symptoms 545
Etiology 545
Treatment 546
Mediastinum, Diseases of the 546
Acute and Chronic Mediastinitis .... 546
Symptoms 547
Acute Mediastinitis 547
Chronic Mediastinitis 547
Abscess of the Mediastinum .... 547
Tuberculous Mediastinal Lym-
phadenitis 548
Tuberculosis of the Bronchial
Glands 548
Diagnosis 549
Treatment 550
Tumors of the Mediastinum 551
Treatment 552
Th\roi(I Gland, Diseases of 552
Functions 552
Hypothyroidia 552
XVI
CONTENTS.
PAGE
Thyroid Gland, Diseases of, Hypothy-
roidia {continued) .
Symptoms 552
Diagnosis 554
Etiology 554
Pathogenesis 555
Treatment 555
Myxedema, or Progressive Hypothy-
roidia ' 555
Definition 556
Symptoms 556
Diagnosis 558
Etiology 558
Treatment 558
Surgical Disorders of the Thyroid Ap-
paratus 559
Injuries 559
Treatment 560
Surger>' of the Thyroid 560
Indications 560
Operative Precautions 561
Operative Technique 562
Thyroid Therapy. See Animal Extracts :
Thyroid Gland.
Thyroidism. See Animal Extracts :
Thyroid Gland.
Thyroiditis. See Goiter.
Thyrotomy. See Larynx, Diseases and
Surgery of.
Tic Douloureux. See Nerves, Peripheral,
Diseases of.
Tinea. See Parasites, Diseases Due to.
Tinea Favosa, Tonsurans, Trichophy-
tina. .See Hair, Diseases of.
Tinea Nodosa. See Piedra.
Tinnitus Aurium. See Internal Ear. Dis-
orders of.
Tobacco 563
Physiological Action 563
Acute Poisoning 563
Chronic Poisoning 563
Treatment of Acute Poisonine 564
Toe, Hammer-. See Orthopedic Surgery.
Toe-nails, Ingrowine. See Nails, Dis-
eases and Injury of.
Tongue, Diseases of 564
Tongue-tie, or Ankyloglossia 564
Treatment 564
Lingual Paoillitis 564
Treatment 565
Parenchymatous Glossitis 565
Symptoms 565
Treatment 565
Chronic Glossitis 565
Svmptoms 565
Treatment 565
Leucoplakia 566
Treatment 566
Eczema of the Tongue 566
Treatment 566
Ulceration of the Tongue 566
Simple Ulcer 566
Syphilitic Ulcer 566
Tuberculous Ulcer 567
Cancerous Ulcer 567
Treatment 567
Tumors of the Tongue 567
PAGE
Tongue, Diseases of. Tumors of the
Tongue {continued) .
Treatment 567
Cancer of the Tongue 567
Symptoms 567
Etiology ■ . 568
Prognosis 568
Treatment 568
Butlin's Technique 568
Whitehead's Technique 569
Kocher's Technique 569
After-treatment 569
Injuries of the Tongue 570
Treatment 570
Tongue-tie. See Tongue, Diseases of.
Tonsils. See Pharynx and Tonsils, Dis-
eases of.
Torticollis. See Muscles, Diseases of.
Toxemia. See Wounds, Septic.
Toxic Foods, or Ptomaine Poisoning .... 570
Meat Poisoning 570
Bacillus Enteritidis 570
Bacillus Botulinus 571
Bacillus Proteus 571
Bacteria of Diseased Meat . . 571
Symptoms 571
Fish Poisoning 572
Symptoms 572
Shellfish Poisoning 572
Symptoms 573
Milk. Cream and Cheese Poisoning . 573
Symptoms 573
Mushroom Poisoning 573
Symptoms 574
Treatment of Food Poisoning 574
Grain and Vegetable Poisoning .... 575
Ergot 575
Chicken-pea 575
Sprouting Potatoes 575
Treatment 575
Pellagra, or Maidism 575
Pathology 576
Symptoms 576
Treatment 576
Trachoma. See Conjunctiva. Diseases
of.
Transfusion. See Venesection and
Transfusion.
Traumatic Neuroses. See Vascular Sys-
tem, Disorders of.
Trematodes. See Parasites, Diseases
Due to.
Tremors 577
Senile Tremor 578
Hysterical Tremor 578
Hereditary or Family Tremor 578
Toxic Tremor 578
Infantile Tremor 578
Intention or \'olitional Tremor . . 578
Etiology and Pathogenesis 579
Treatment 579
Paralysis .A.gitans (Parkinson's Dis-
ease; Shaking Palsy) 580
Symptoms 580
Diagnosis 582
Etiology, Pathogenesis, and Path-
ology 582
CONTENTS.
xvii
PAGE
Tremors, Paralysis Agitans (Parkinson's
Disease; Shaking Palsy) (continued).
Treatment 583
Multiple Sclerosis 585
Synonyms 585
Definition 585
Symptoms 585
Diagnosis 586
Etiology 586
Pathology 587
Prognosis 587
Treatment 587
Trichocephalus Dispar. See Parasites,
Diseases Due to.
Trichophytosis 588
Symptoms 588
Etiology 588
Prognosis 588
Treatment 588
Trigger Finger. See Tendons, Bursse
and Fascise, Diseases of.
Trional 589
Physiological Action 589
Poisoning by Trional 589
Treatment 589
Therapeutic Uses 590
Tropacocaine 590
Physiological Action 590
Untoward Symptoms 590
Therapeutic Uses 590
Trypanosomiasis, or Sleeping Sickness. 591
Symptoms 591
Diagnosis • • 591
Prophylaxis 591
Treatment 592
Tuberculosis, Acute 592
Acute Miliary Tuberculosis 593
Symptoms and Diagnosis 593
General or Typhoid Form 593
Pulmonary Form 594
Meningeal Form 594
Diagnosis 595
Pathology 595
Treatment 595
Acute Pneumonic Phthisis 596
Symptoms 596
Treatment 596
Tuberculosis, Chronic Pulmonary 597
Symptomatology 597
Loss of Strength 597
Indigestion 597
Anorexia 598
Anemia 598
Autonomic Disturbances 598
Lowered Blood-pressure 598
Increased Pulse Frequency 598
Fever 598
Cough 598
Expectoration 598
Hemoptysis 598
Hoarseness 599
Pain 599
Night-sweats 599
Emaciation 599
Dyspnea 599
Diarrhea 599
Neuritis 599
PAGE
Tuberculosis, Chronic Pulmonary,Symp-
tomatologv (continued).
Psychical Changes 599
Physical Examination 599
Inspection 599
Palpation 601
Percussion 601
Auscultation 603
X-ray Examination 606
The Blood 606
Sputum : Microscopic Examination
of 607
Diagnosis 608
Differential Diagnosis 609
Etiology and Pathogenesis 609
Pathology 611
Prognosis 612
Treatment 613
Fresh Air 613
Rest 614
Exercise 614
Respiratory Exercises 615
Diet 615
Clothing ■ • . 616
Bathing 616
Chest Compress 617
Tuberculins and Sera 617
Iodine 619
Creosote and its Derivatives 620
Arsenic and its Compounds 620
Calcium 620
Thyroid Gland 620
Nuclein 620
Cinnamic Acid 621
Mercury 621
Strychnine 621
Ichthyol 621
Camphor 621
Digitalis 621
Nitroglycerin 621
Quinine 621
Urea 622
Iron 622
Other Drugs 622
Surgical Treatment 622
Artificial Pneumothorax : 622
Chondrotomy 623
Extra-plcural Thoracoplasty 623
Inhalations 623
Treatment of Symptoms 623
Fever 623
Night-sweats 623
Cough 623
Hemoptysis 623
Prophylaxis 623
Tuberculosis of the Serous Membranes
and Skin 625
Mescntric Tuberculosis or Tabes
Mesenterica 625
Symptoms 625
Diagnosis 625
Prognosis 626
Treatment 626
Tuberculosis of the Myocardium 626
Treatment 626
Tul)crculosis of the Skin 626
Scrofuloderma 626
XVlll
CONTENTS.
PAGE
Tuberculosis of the Serous Membranes
and Skin, Tuberculosis of the Skin,
Scrofuloderma {c(»iliiiucd }.
Symptoms 626
Etiology and Pathogenesis 626
Treatment 627
True Tuberculosis or Tul)erculosis
Cutis 627
Treatment 627
Tuberculosis Verruca Cutis 627
Symptoms 627
Treatment 627
Lupus Vulgaris 627
Symptoms 628
Diagnosis 628
Etiology and Pathology 628
Prognosis 628
Treatment 629
Lupus Erythematosus 630
Symptoms 630
Etiology 631
Treatment 631
Turpentine (Terebene; Terpin Hy-
drate ) 632
Preparations and Doses 632
Physiological Action 633
Untoward Effects and Poisoning 633
Treatment of Poisoning 633
Therapeutics 633
Twilight Sleep. See Scopolamine.
Typhlitis. See Appendicitis.
Typhoid Fever 635
Symptoms 635
Varieties of Typhoid Fever 637
The Temperature 637
Chills 638
The Skin 638
Bed-sores 639
The Digestive System 639
The Stomach 639
The Intestines 639
Meteorism 639
Pain 639
The Rectum 640
The Abdominal Organs 640
The Gall-bladder 640
The Spleen 640
The Respiratory System 640
The Circulatory System 640
Blood-pressure 640
The Nervous System 640
The Genitourinary System 641
The Reproductive Organs 641
Complications 641
Perforation 642
Diagnosis 644
The Bordet-Gengou Reaction 645
The Ophhalmic Reaction in Ty-
phoid 646
Isolation of Typhoid Bacilli from
Body Fluids 646
Etiology 647
Pathology 649
Histology 650
The Blood in Typhoid Fever 650
Prognosis 651
Age 651
PAGE
Typhoid Fever, Prognosis (continued) .
Habits 651
Severity of Infection 651
Complications 651
Per f oration 65 1
Relapse 651
Treatment 651
1. Diet and General Management . . . 652
2. Hydrotherai)y 654
3. Medicinal Treatment 655
4. Vaccine and Serum Treatment . . 656
5. Treatment of Complications .... 656
Treatment of Convalescence 657
The Public Health Aspect of Typhoid
Fever 657
Purification of Water 658
Filtration 658
Slow Sand Filters 658
Mechanical Filters 659
Chlorine Gas 660
Flies ih Tj'phoid P'ever 660
Prophyla.xis 661
Typhoid Vaccination 663
Paratyphoid Fever 663
Symptoms 663
Complications 664
Diagnosis 664
Treatment 664
Typhoid Fever in Infancy 664
Typhoid Fever in Early Childhood . . 665
Typhoid Fever in Later Childhood . . 665
Typhus Fever 665
Definition 665
Symptoms 665
Brill's Disease 666
Diagnosis 666
Etiology and Pathologv 667
Prognosis 667
Prophylaxis 668
Treatment 668
Ulcers and Varicose Ulcers. See Vas-
cular System, Surgical Dis-
eases of.
Uremia 668
Symptoms 669
Acute Uremia 669
Chronic Uremia 669
Diagnosis 670
Etiology 671
Treatment 671
Urea, Determination of 672
Specific Gravity Method 672
Sodium Hypobromite Method 672
Davy's Method 673
Benedict's Method 673
Folin's Method 673
Marshall's Method 674
Ureters. See Kidneys and Ureters.
Diseases of.
Ureters and Bladder, Examination of.
Cystoscopy 675
Varieties of Cystoscope 675
Preparation of the Cystoscope for
Use 675
Preparation of the Patient 676
General Anesthesia 676
CONTENTS.
XIX
PAGE
Ureters and Bladder, Examination of,
Cystoscope (continued).
Technique of Cystoscopy 676
Uses of Cystoscopy 677
Ureteral Catheterizaion 678
Urinary Segregation 678
Urethane 679
Physiological Effects 679
Poisoning by Urethane 679
Treatment of Poisoning 679
Therapeutic Uses 679
Urethra. See Urinary and General Sys-
tems, Surgical Diseases of.
Urinalysis. See Index under titles of
various abnormal conditions
of Urine : Albuminuria. Lac-
tosuria, Tyrosinuria, etc.
Urinary and Genital Systems, Surgical
Diseases of 679
Diseases of the Urethra 679
Anomalies of the Urethra 679
Congenital Occlusion 679
Congenital Stricture 679
Urethral Pouches 679
Epispadias 680
Treatment 680
Hypospadias 680
Treatment 680
Injuries of the Urethra 681
Rupture of the Urethra 681
Symptoms 681
Treatment 682
Foreign Bodies and Calculi in the
Urethra 683
Symptoms 683
Diagnosis 683
Treatment 683
Gonorrhea 684
Definition 684
Symptoms 684
Acute Gonococcal Urethritis . . . 684
Chronic Gonococcal Urethritis . 685
Diagnosis 685
Complications 686
Prophylaxis 686
Abortive Treatment 687
Repressive Treatment 687
Treatment of Chronic Gonorrhea . 691
Gonorrhea in Women 692
Urethra 693
Treatment 693
Vagina and Vulva 693
Symptoms 693
Treatment 693
Periurethritis and Urethral Fistula . 694
Treatment 694
Cowpcritis 695
Treatment 695
Non-gonorrheal Urethritis 695
Symptoms 695
Diagnosis 695
Treatment 695
Stricture of the Urethra 695
Varieties 696
Symptoms 696
Diagnosis 696
Etiology_ 697
PAGE
Urinary and Genital Systems, Surgical
Diseases of, Diseases of the Urethra,
Stricture of the Urethra {continued) .
Treatment 697
Dilatation 697
Urethrotomy 698
Internal Urethrotomy 698
External Urethrotomy 699
A. With a Guide — Syme's
Operation 699
B. Without a Guide— Peri-
neal Section 699
Urethral, Urinary, or Catheter
Fever 699
Symptoms and Etiology 699
Acute Urinary Septicemia 699
Chronic Urinary Septicemia .... 700
Treatment '. 700
Chancroid 700
Definition 700
Symptoms 700
Etiology 701
Diagnosis 701
Complications 701
Treatment 702
Tumors of the Urethra 702
Treatment 703
Diseases of the Prostate 703
Anomalies 703
Injuries of the Prostate 703
Etiology 703
Treatment 703
Foreign Bodies and Calculi in the
Prostate 704
Symptoms 704
Etiology 704
Diagnosis 704
Treatment 704
Acute Prostatitis 704
Symptoms 704
Etiology 705
Treatment 705
Chronic Prostatitis 706
Symntoms 706
Diagnosis 706
Etiology 707
Treatment 707
Abscess of the Prostate 708
A Symptoms 708
Etiology 7aS
Treatment 708
Prostatorrhea 70S
Symptoms 708
Etiology 709
Treatment 709
Atrophy of the Prostate 709
Hypertrophy of the Prostate 7t)9
Symptoms 709
Diagnosis 710
Etiology and Pathology 711
Prognosis 712
Treatment 712
Operatiye Treatment 713
Vasectomy 713
Castration 714
Galvanocauterization 714
A. Bottini's Operation .... 714
XX
CONTEXTS.
PAGE
'Urinary and Genital Systems, Surgical
Diseases of, Diseases of the prostate,
Hypertrophy of the prostate, Operative
Treatment, Galvanocauterization (con-
tinued).
B. Chetwood's Operation . . 714
Cystostomy 714
Prostatectomy 715
Suprapubic Prostatectomy . . . 715
Perineal Prostatectomy . . . 715
A. Median 715
B. Extra-urethral 715
Tuberculosis of the Prostate 716
Symptoms ' 716
Diagnosis 716
Etiology 716
Treatment 716
Tumors of the Prostate 717
Cysts 717
Carcinoma 717
Symptoms 717
Diagnosis 717
Treatment 717
Sarcoma 718
Treatment 718
Diseases of the Bladder 718
Anomalies 718
Treatment 718
Exstrophy of the Bladder 718
Treatment 718
Retention of Urine 719
Definition 719
Symptoms 719
Etiology 719
Complications and Sequelae 720
Treatment 720
Rupture of the Bladder 722
Symptoms and Diagnosis 722
Treatment 723
Cystocele 723
Treatment 723
Foreign Bodies in the Bladder .... 723
Symptoms 724
Diagnosis 724
Treatment 724
Vesical Calculus 724
Symptoms 725
Diagnosis 726
Treatment 726
Lithotomy 727
Technique of Litholapaxy 727
Technique of Lithotomy 728
Perineal Lithotomy, Lateral . . 729
Median .......' 730
Suprapubic Lithotomy 730
Tuberculosis of the Bladder 731
Symptoms 731
Diagnosis 732
Treatment 732
Tumors of the Bladder 733
Varieties 733
Symptoms 733
Etiology and Pathology 733
Diagnosis 734
Prognosis 734
Treatment 734
Ulcer of the Bladder 735
PAGE
LIrinary and Genital Sysems, Surgical
Diseases of, Diseases of the I'laddcr,
Ulcer of the Blader (continued).
Diagnosis 736
Treatment 736
Varicose Veins of the Bladder 736
Treatment 736
Fistula of the Bladder 736
Treatment 736
Diseases of the Seminal Vesicles 736
Anomalies 736
Wounds 736
Concretions 737
Treatment 737
Acute Seminal Vesiculitis 737
Symptoms 737
Diagnosis 737
Treatment 737
Chronic Seminal Vesiculitis 737
Symptoms 737
Diagnosis 737
Treatment 737
Tuberculosis of the Seminal Vesicles. 738
Symptoms 738
Diagnosis 738
Treatment 738
Tumors 738
Diseases of the Spermatic Cord 738
Anomalies 738
Wounds 738
Treatment 738
Torsion 739
Inflammation 739
Treatment 739
Hydrocele of the Cord 739
Treatment 739
Solid Tumors 739
Urobilinuria 740
Urticaria 740
Definition 740
Synonyms 740
Symptoms 740
Urticaria Papulosa (Lichen Urti-
catus) 740
Urticaria Bullosa 740
Urticaria Nodosa (U. Tuberosa ) .. 740
Urticaria Hemorrhagica 740
Urticaria Intermittens 740
L^rticaria Perstans 740
Urticaria Pigmentosa 741
Diagnosis 741
Etiology 741
Pathology 741
Prognosis 741
Treatment 741
Litems, Diseases of 742
Malformations 742
Rudimentary Uterus 742
Abscess of the Uterus 742
Embryological Malformations 742
One-horned Uterus 742
Two-horned Uterus 742
Double Uterus 742
Two-chambered Uterus 742
Fetal Uterus 743
Infantile Uterus 743
Puerile Uterus 743
CONTENTS.
XXI
PAGE
Uterus, Diseases of, Embryological Mal-
formations (continued).
Puerile Cervix 743
Symptoms and Diagnosis 743
Treatment 743
Stenosis of the Cervix 744
Symptoms 744
Diagnosis 744
Prognosis 744
Treatment 744
Laceration of the Cervix 745
Symptoms and Diagnosis 745
Pathology 745
Treatment 745
Displacements of the Uterus 746
Etiology 746
Anteflexion and Anteversion 748
Symptoms 748
Diagnosis 748
Treatment 748
Retroflexion and Retroversion 749
Symptoms 749
Diagnosis 749
Treatment 749
Prolapse and Procidentia 750
Symptoms 750
Diagnosis 750
Treatment 750
Inversion of the Uterus 751
Symptoms and Diagnosis 751
Prognosis 752
Treatment 752
Tuberculosis of Uterus and Adnexa . . 753
Tuberculosis of the Body of Uterus . 753
Symptoms and Diagnosis 753
Treatment 753
Tuberculosis of the Cervix 753
Symptoms 753
Prognosis 753
Treatment 753
Tumors of the Uterus 753
Myoma of the Uterus 753
Symptoms 754
Diagnosis 754
Etiology 755
Pathology 755
Prognosis 755
Treatment 755
Carcinoma of the Uterus 757
Cervix Uteri 757
Squamous-cell Carcinoma 757
Cylindrical-cell Carcinoma ... 75S
Symptoms and Diagnosis 758
Prognosis 759
Treatment 759
Corpus Uteri 760
Symptoms 760
Diagnosis 760
Prognosis 760
Treatment 761
Dcciduoma Malignum 761
Treatment 761
Sarcoma of the Uterus 761
Sarcoma of the Cervix 761
Symptoms and Diagnosis 761
Sarcoma of the Endometrium .... 761
Interstitial Sarcoma 762
PAGE
Uterus, Diseases of. Tumors of the
Uterus, Sarcoma of the Uterus, Inter-
stitial Sarcoma {continued).
Symptoms 762
Diagnosis 762
Treatment 762
Uva Ursi 762
Preparations and Doses 762
Physiological Action 762
Therapeutic Uses 762
Uveal Disorders. See Iris, Ciliary Body
and Choroid.
Uvula. See Pharynx and Tonsils, Dis-
eases of.
Vaccination. See Varioloid and Vac-
cination.
Vagina and Vulva, Diseases of 763
Acute Vulvovaginitis 763
Symptoms 763
Etiology 763
Treatment 764
Chronic Vulvitis 764
Follicular Vulvitis 764
Glandular Vulvitis 765
Treatment 765
Gonorrheal Vulvovaginitis 765
Diagnosis 765
Etiology 766
Treatment 766
Infectious Vaginitis 766
Tuberculous Vulvovaginitis 766
Symptoms 766
Treatment 767
Diphtheritic Vulvovaginitis 767
Treatment 767
Puerperal Vulvovaginitis 768
Treatment 768
Eczematous Vulvovaginitis 768
Etiology 768
Treatment 768
Leucorrhea 769
Symptoms 769
Etiology 769
Treatment 769
Atrophy of the Vagina and Vulva . . . 770
Hypertrophy of the Vagina and Vulva 770
Treatment 770
Prolapse of the Vagina 771
Treatment 771
Vaginismus 771
Treatment 771
Vaginal Fistulae 772
Treatment 772
Mayo's Technique 772
Tumors of the Vagina and Vulva .... 773
Benign 773
Malignant 773
Hcrnije 773
Treatment 774
Cysts 774
Treatment 774
Hematomata 774
Treatment 775
Miscellaneous Growths 775
Treatment 775
Fungous Growths 775
xxn
CONTENTS.
PAGE
Vagina and Vulva, Diseases of, Tumors
of the Vagina and Vulva. Fungous
Growths (coiilinucd) .
Treatment 775
Foreign Bodies 775
Treatment 775
Malignant Growths 775
Treatment 776
Congenital Absence 776
Treatment 776
Adhesions 777
Acquired Occlusion 777
Varicocele 777
Treatment 777
Parasitic Vulvitis 777
Treatment 777
Kraurosis Vulva; 778
Treatment 778
Pruritus Vulvae 778
Treatment 778
Vaginoperineal Injuries. See Pregnancy
and Parturition, Disorders of.
Vagotonia and Sympatheticotonia 780
Symptoms 780
Pathology 780
Treatment 780
Valerian 780
Preparations and Doses 780
Physiological Action 780
Therapeutics 781
Valvular Diseases of the Heart. See
Endocardium and Heart,
Diseases of.
Varicella 781
Definition ■ • 781
Symptoms 781
Diagnosis 781
Etiology 782
Prognosis 782
Treatment 782
Varicocele. See Penis and Testicles,
Diseases and Injuries of.
Variola (Smallpo.x) 782
Definition 782
Symptoms 782
Special Forms 783
Diagnosis 783
Scarlatina 783
Measles 783
Typhoid Fever 783
Influenza 783
Meningitis 783
Cerebrospinal Meningitis 783
Etiology 783
Prophylaxis 784
Treatment 784
Varioloid and Vaccination 785
Varioloid 785
Vaccination 785
Technique 785
Prevention of Infection 786
Acupuncture Method 786
Symptoms 787
Revaccination 787
Efficacy of Vaccination 787
Vascular System, Disorders of 788
Raynaud's Disease 788
PAGE
Vascular System, Disorders of, Raynaud's
Disease (continued).
Symptoms 788
Etiology and Pathogenesis 788
Treatment 789
Erythromelalgia 790
Symptoms 790
Etiology and Pathology 790
Treatment 790
Acroparesthesia 791
Symptoms 791
Etiology and Pathology 791
Pathogenesis 791
Treatment 792
Vasomotor Ataxia 792
Symptoms 792
Diagnosis 793
Treatment 793
Traumatic Neuroses 794
Pathogenesis 794
Symptomatology 795
Vascular System, Surgical Diseases of . 797
Acute Arteritis 797
Symptoms 797
Treatment 797
Phlebitis 797
Symptoms 797
Etiology 797
Prognosis 797
Treatment 798
Venous Varix, or Varicose Veins 798
Symptoms 798
Etiology 798
Pathology 798
Treatment 798
Palliative Measures 798
Radical Treatment 798
Hemorrhage 799
Symptoms 799
Treatment 799
Injuries and Wounds of Vessels 800
A. Arteries 800
Contusion 800
Rupture 800
Punctured Wounds 800
Incised Wounds 800
B. Veins 800
Treatment 800
Secondary Hemorrhage 801
Venous Hemorrhage 801
Thrombosis 801
Varieties 801
Symptoms 801
Etiology 801
Pathology 802
Treatment 802
Phlegmasia Alba Dolens 802
Symptoms 802
Diagnosis 803
Etiology 803
Pathology 803
Complications 803
Sequelc-e 803
Prognosis 803
Treatment 803
Vasomotor Neuroses. See Vascular Sys-
tem, Disorders of.
CONTENTS.
xxni
PAGE
Veins, Disorders of. See Vascular
System.
Venesection and Blood Transfusion .... 803
Venesection 803
Technique 803
Indications 804
Blood Transfusion 804
Technique 804
Indications 805
Venomous Bites. See Index.
Veratrum 805
Preparations and Doses 805
Physiological Action 805
Untoward Effects and Poisoning 806
Treatment of Poisoning 806
Therapeutics 806
Veronal 807
Physiological Action 807
Poisoning by Veronal 807
Treatment of Poisoning by Veronal . 807
Therapeutic Uses 807
Vitamines 808
Warts. See Skin, Surgical Diseases of...
Water (Hydrotherapy) 809
Reaction . 809
Temperature of Baths 809
Hydrotherapeutic Measures 809
The Cold Pack 809
Evaporation Bath 809
The Cold Bath 810
The Half-bath of Priessnitz 810
The Spray Bath 810
The Ablution or Wet-mit Friction . 810
The Drip Sheet or Sheet Bath 810
Sponging 811
The Oil Rub 811
The Scotch Rub 811
Salt Rub or SaU Glow 811
Ice Rub or Ice Ironing 811
Alcohol Rub 811
Douches 811
Cold Applications 812
Hot Applications 812
Needle Douche or Spray ; Circular
Douche 812
Cold Douche 812
Spinal Douche 812
Alternating Hot and Cold Douches
(Scotch Douche) 812
Head Douches 812
Rain Douche 812
Fan Douche 812
Filiform Douche 812
Perineal Douche 812
Aix Douche 813
Affusions 813
Continuous Baths 813
The Warm Full Bath 813
Prolonged Warm Baths 813
Warm Baths of Short Duration .... 813
The Hot Rath 813
Special Baths 813
The Brand Bath 813
The Turkish Bath 813
The Russian Bath (Diaphoretic) ... 814
Vapor or Sweating Bath 814
PAGE
Water (Hydrotherapy), Special Baths
(cotitinucd) .
Foot-bath 814
Medicated Baths 814
Alkaline Bath 814
Pine-needle Bath 814
Sulphur Bath 814
Packs 814
Cold Wet Pack 814
Hot Wet Pack 814
Dry Hot Pack 814
Compresses 814
Cold Compress 814
Ice Compresses 815
Hot Compresses (Fomentations) ... 815
Weil's Disease. See Liver and Gall-blad-
der : Acute Infectious Jaun-
dice.
Wen. See Skin, Surgical Diseases of.
Whooping-ceugh. See Pertussis.
Wintergreen. See Gaultheria.
Witchhazel. See Hamamelis.
Worms. See Parasites, Diseases Due to.
Wounds, Septic and Sepsis 815
Prophylaxis 815
Commonly Used Antiseptics 815
Sodium Hypochlorite or Dakin-Car-
rel Solution .- . . 816
Daufresne's Technique 816
Wound Excision and Primary Suture . 819
Delayed Primary Suture 820
Secondary Suture 820
General Infections; Sepsis 822
Toxemia or Sapremia 822
Septicemia 823
Pyemia 824
Etiology and Pathology 825
Toxemia or Sapremia 825
Septicemia, Sepsis, Septic Infec-
tion 826
Pyemia 826
Prognosis 826
Treatment 827
Local Measures 827
Dichloramine-T 828
Flavine 830
Brilliant Green 830
Bismuth Iodoform Paste 831
Serums and Vaccines 833
Babcock's Method 833
General Measures 834
Puerperal Sepsis 835
Symptoms 835
Etiology 836
Diagnosis 836
Treatment , 837
Wounds, Venomous. See Wounds and
Stings.
Xanthoma 837
Etiology 837
Pathology 837
Prognosis 838
Treatment 838
Xanthoma Diabeticorum 838
Pathology 838
Prognosis 838
XXIV
CONTEXTS.
PAGE
Xanthoma Diabeticorum (continued).
Treatment 838
X-ravs and Radium 838
X-rays 838
Physiological Action 838
Untoward Effects 839
Therapeutic Dosage 839
Apparatus 839
Estimation of Dosage 840
Filters 841
Therapeutic Uses 841
Diseases which Benefit by X-ray
Stimulation 841
Diseases which Benefit by Reduc-
tion of Tissue Activity .841
Diseases which Benefit by Destruc-
tion of Cells 841
Radium 841
Physiological Action 841
Therapeutic Uses 842
Yaws 843
Synonyms 843
Symptomatologv' 843
The Primary or Prodromal Stage .. 843
The Secondary or Granulomatous
Stage 843
The Tertiary Stage 843
Infection 843
Treatment 843
Prophylaxis 843
Yellow Fever 843
Symptomatology 844
PAGE
Yellow Fever, Symptomatology (con-
tinued).
Fulminant Cases 844
Diagnosis 844
Etiology 845
Pathology and Pathogenesis 845
Prognosis 845
Prophylaxis 845
Treatment 846
Yohimbine 846
Physiological Action 846
Untoward Effects 846
Therapeutic Uses 846
Zinc 847
Preparations and Doses 847
Irritant (Soluble) 847
Mild (Insoluble) 847
Physiological Action 848
Acute Poisoning by Zinc Salts 848
Chronic Poisoning 848
Treatment of Acute Poisoning 849
Therapeutics 849
Gastrointestinal Disorders 849
Respiratory Disorders 849
Nervous Disorders 849
Cutaneous Disorders 850
Catarrhal Disorders 850
Zingiber 850
Preparations and Doses 850
Physiological Action 850
Therapeutic Uses 850
Zona. See Herpes Zoster.
/
SAJOUS'S
ANALYTIC CYCLOPEDIA
of PRACTICAL MEDICINE
R
R H E U M AT I S M. — A group of
affections, sometimes of parasitic
origin, characterized by pain and
swelling of the joints and muscles,
and which may be acute or chronic.
Under this term may be grouped
rheumatic fever, muscular rheuma-
tism, and various joint manifestations
dependent upon specific infections
such as gonorrhea, scarlatina, diph-
tlieria, etc. Of these conditions, the
first three will be considered seriatim
in this article.
Rheumatoid arthritis or, according
to the newer classification of Gold-
thwait, (1) chronic atrophic arthritis,
and (2) chronic hypertrophic ar-
thritis, have been considered in the
article on Joints, Surgical Diseases
OF, in vol. vi.
RHEUMATIC FEVER.
Rheumatic fever {acute or subacute
rheumatism; acute articular rheuma-
tism), is an acute and subacute infec-
tious, febrile disease, characterized
by migratory, multiple artl^ritis, sweat-
ing, and a tendency to complicating
inflammation of the serous membranes
and the fibrous tissues, and to re-
currence.
SYMPTOMS. — Rheumatic fever
rarely presents marked i)rodromal
symptoms, but ordinarily the patient
feels weary and ill for from one to
three days. Occasionally fugitive
pains, sore throat, or otitis media
precede the onset of the disease.
The symptoms of the acute affection
then set in suddenly with chills, which
may be repeated once or twice.
Fever appears and the temperature
rises to 39° or 40° C. (102.2° or
104° F.) ; the pulse and respiration
are accelerated, the tongue furred;
there is no appetite, but thirst is
marked. The urine is scanty, highly
acid, and loaded with urates, which
give it a dark-red color and rapidly
precipitate; the specific gravity of the
urine is high, and it is not rare to ob-
serve albuminuria on the first days of
the disease. Chemical examination
demonstrates that urea as well as
uric acid is present in excessive
quantity. Hemoglobinuria, pepto-
nuria, urobilinuria, and cystinuria
have sometimes been observed.
The skin is covered with abundant
perspiration and numerous sudamina
and miliaria often appear on it. The
sweat is acid and of a peculiar odor.
Simultaneously with the fever the
characteristic signs of rheumatic ar-
thritis appear, generally in the articu-
(1)
RHEUMATISM (LEVISON AND SAJOUS).
lations of the foot or the knee. Fre-
quently the affection begins in the
ankle-joint, and after some days the
process also invades the knee, the
shoulder, the elbow-joint, and the
wrist. Occasionally the affection
begins in the joints of the upper ex-
tremities. This, when it is the case,
ordinarily occurs in persons occupied
in hard bodily work. The larger
joints are most frequently affected,'
but sometimes the small joints of the
fingers and toes are also involved,
especially in children. A single joint
rarely continues to be the seat of
trouble for more than four or five
days ; the affection then more or less
suddenly disappears, commonly dur-
ing the night, and one or more other
joints are attacked in turn. At one
time several joints may be involved
to a varying extent. In very severe
cases almost all joints may be af-
fected simultaneously, and even the
articulations of the jaws, the spine,
and the ribs may be painful and swol-
len. Ordinarily rheumatic fever at-
tacks several articulations, but mon-
articular acute rheumatism has also
been observed.
According to statistics, the locali-
zation of the disease in the different
joints is as follows : Ankle, 27.8 per
cent. ; knee, 17.9 per cent. ; wrist, 9.6
per cent. ; shoulder, 6.2 per cent. ; hip,
4.1 per cent. ; metatarsus, Zj per
cent. ; elbow, 2.2 per cent. ; metacar-
pus, 1.2 per cent.; toes, 0.8 per cent.;
fingers, 0.8 per cent.
Analyzing 100 cases of so-called
"rheumatism," the author found that
these included 44 cases of arthritis
and 3 of muscular rheumatism to
which the term "rheumatism" might
be fairly applicable. Thirty of the
44 patients gave a history of gonor-
rhea. Among the 53 incorrectly
diagnosed cases there were 18 of
syphilis, with a positive Wassermann,
8 of neuritis, 4 of tuberculosis, 4 of
flat foot, 3 typical cases of pellagra,
2 each of neurasthenia, arterioscle-
rosis, sciatica, and tabes, and 1 each
of chronic nephritis, chronic gas-
tritis, muscular atrophy, malaria, per-
nicious anemia, and myelitis. Deade-
rick (South. Med. Jour., Dec, 1918).
The affected joints are very painful
and swollen ; the overlying skin is
red, hot, tense, and edematous, while
pressure upon it leaves an impression
which remains visible for some time.
Swelling of the joint is caused prin-
cipally by edema of the skin and
ligaments, but occasionally also by
an effusion in the articulation itself.
Upon moving the diseased articula-
tion a crackling sound is sometimes
heard ; this is commonly caused by
the inflammatory changes in the ten-
dons and their synovial membranes.
Moving and even touching the af-
fected joints is very painful to the
patient; in severe cases the pain may
be occasioned by very small commo-
tions, e.g., by walking over the floor
of the sick-room. The pain seems to
be localized in the tendons and the
muscles in the proximity of the joint.
When the patient is induced to keep
completely quiet, slight movements
of the diseased joint may be passively
executed without causing any pain,
whereas the most trifling active
movement is accompanied by ex-
cruciating pain.
The skin over the affected articu-
lation shows increased sensibility to
changes of temperature, but a dimin-
ished sensibility to faradic irritation.
Of diagnostic importance in the
cases in which they are present are
small nodules — "rheumatic nodules"
— 1 to 4 mm, in diameter, generally
RHEUMATISM (LEVISON AND SAJOUS).
not tender, appearing- in areas where
bones underlie the skin or in the
synovial sheaths of tendons. These
occur especially in children. They
may disappear rapidly or only after
some months. Fibrosis may occur in
them.
The temperature of the patient is
elevated in proportion to the number
of the affected articulations ; in un-
complicated cases it seldom rises
above 39° to 40° C. (102.2° to
104° F.), but it may also oscillate be-
tween 38° and 39° C. (100.4° and
102.2° F.). Acid sweats often take
place consentaneously with remis-
sions in the temperature.
One of the earliest and most con-
stant and obscure symptoms of rheu-
matism in children is a persistent low
fever, dropping- daily to normal, occa-
sionally below, and seldom going
above 100° F. The child usually feels
well, looks well, and the condition is
only accidentally discovered. The
first suggestion occurs after an illness
during which time there has been ele-
vation of temperature, but as the
other symptoms clear up the tempera-
ture chart reveals the persistence of
a small amount of unaccountable
fever. A complete examination may
disclose no symptoms other than
slight acceleration of the heart on
exertion. One naturally thinks of tu-
berculosis, but gets a negative von
Pirquet. Poynton considers this tem-
perature an important diagnostic
symptom of very early rheumatic in-
fection. J. A. Colliver (Arch, of
Pediat, Jan., 1914).
The pulse is soft and usually above
100 in rate. Evidences of toxemia,
such as coated tongue, constipation,
and splenic enlargement are likely to
be observed.
The duration of rheumatic fever
varies from some days to several
weeks or even months ; it is liable to
remissions and exacerbations, and,
especially when the patient leaves the
bed or the sick-room too soon, exacer-
bations are frequently observed. In
some cases, the fever having- de-
clined, one or more joints remain
swollen and painful for a long time.
A critical decline of the temperature
is rarely observed.
When the joint swellings subside
the cuticle commonly cracks and
peels off in small scales. As many
red blood-corpuscles become de-
stroyed during a severe attack of
rheumatic fever, the patients get
pale and weary. The anemia often
continues for a long- period after re-
covery from the disease itself. Leu-
cocytosis, up to a maximum of 20,000,
has been observed to develop early in
the rheumatic attack and to decline
with equal rapidity during- con-
valescence.
Some authors refer to a larval form
of rheumatic fever, characterized by
neuralgia of, e.g., the trifacial or the
sciatic nerve, accompanied by high
fever, but without involvement of the
joints, and yielding rapidly to the use
of salicylates. During an epidemic of
rheumatic fever endocarditis or peri-
carditis with high fever is sometimes
observed in patients who do not suf-
fer from any involvement of the ar-
ticulations ; such cases have been
denominated polyarthritis rhcumatica
sine arthritide.
COMPLICATIONS.— These are
very frequent and aft'ect especially
the heart and the nervous system.
Verrucose and even ulcerative endo-
carditis is observed in a large pro-
portion of cases, especially when the
fever is high and many joints are
affected. Pericarditis is not quite so
frequently observed. Endocarditis
RHEUMATISM (LEVISON AND SAJOUS).
has been estimated to occur in about
20 per cent, of all cases, and pericar-
ditis in about 14 per cent. ; but these
proportions vary, the epidemics of
rheumatic fever differing very much
in regard to severity and frequency
of complications. Bosanquet, in a
series of 450 cases, noted endocar-
ditis in 28 per cent, of the males and
33 per cent, of the females, and some
observers place the incidence of endo-
carditis at 50 to 75 per cent. The
likelihood of endocarditis is increased
by youth of the patient and where
preceding attacks have occurred.
The mitral valve is that oftenest in-
volved. Pericarditis is observed in
the majority of the cases ending
fatally, and may be fibrinous, sero-
fibrinous, or purulent.
In almost all cases some dilatation
of the right heart due to toxic myo-
carditis, is found. A murmur heard
over the heart is thus often not due
to endocarditis, but to cardiac dilata-
tion (or to anemia). In consequence
of endocarditis, the myocardium may
also be affected either by simple ex-
tension through contiguity or by em-
boli. A condition of complete car-
diac inflammation or pancarditis may
occur. Slight weakening of the myo-
cardium may be manifested by gen-
eral weakness, attacks of pain, or
tachycardia. The symptoms of endo-
carditis and pericarditis are discussed
elsewhere in this work.
D. B. Lees describes the cardiac
complications of rheumatism in child-
hood as follows : The first indication
of endocarditis is a systolic murmur
at the apex. Often the second sound
becomes doubled, after a time, the
doubling being heard only in the
apex region, different from the dupli-
cated pulmonary sound of advanced
mitral stenosis. The first element of
the second sound always remains
sharp and short as long as it is
audible at all. The second element
may be substituted by a short blow-
ing, early diastolic or middiastolic
murmur. At a later stage there may
be at the apex a presystolic murmur,
followed by a longer and louder sys-
tolic. This presystolic murmur is
blowing in character, usually short,
common in children after a rheumatic
attack, and generally accompanied
by evidences of great dilatation of the
heart. Care should be taken not to
consider a soft, double sound at the
base an evidence of commencing
aortic disease. It is often the first
indication of pericarditis.
While in adults the disease spends
itself chiefly upon the joints, in the
child it has a much greater tendency
to attack the heart; the joint involve-
ment in the latter is often so slight
as to be overlooked, yet the cardiac
• involvement may be severe. Ton-
sillitis is in the child a frequent pre-
cursor of rheumatism, while chorea
is at times a sequel. Cardiac involve-
ment might come w^ithin 24 hours of
the beginning of the rheumatic at-
tack and its discovery depends upon
a careful routine study of the heart.
The mitral lesions thus caused are
capable of complete recovery, though
the aortic lesions practically never
recover. D. Riesman (Trans. Phila.
Co. Med. Soc; Med. Rec, Apr. 16,
1921J.
Rheumatism in the child can be
discovered at the age of 5 years, pos-
sibly earlier. Earlier signs of the
disease are an incessant restlessness,
a constantly accelerated pulse rate,
often reaching 100 or over, and very
frequently a constant fever of a little
over 99° F. (37.2° C.) to a little more
than 100° F. (37.8° C). That such
a rise of temperature and of pulse
rate are not due to nervous excite-
RHEUMATISM (LEVISON AND SAJOUS).
merit is proved by their being found
for years in the same child and
always at about the same level for
any one child. This observation is
based upon over SOOO temperature
r-ecords. M. H. Williams (Lancet,
June 19, 1915).
Very dangerous and rather fre-
quent are the complications involving-
the brain. In some cases the symp-
toms are only caused by hyperpy-
rexia; when the temperature rises to
41° or 42° C. (105.8° or 107.6° F.)
or even to 43° C. (109.4° F.), when
sweating is very profuse, and signs
of endocarditis develop, there is im-
minent danger of cerebral rheuma-
tism. When symptoms of meningitis
occur, they are not necessarily due
to actual inflammation of the menin-
ges, but may be caused by hemor-
rhage, edema, or hyperemia. A
uremic condition of the blood may
also lead to cerebral symptoms.
Cerebral rheumatism may manifest
itself in different ways : —
1. When it is foudroyant the pa-
tient is suddenly seized with agita-
tion ; although previously unable to
make a movement without extreme
pain, he now leaves the bed and
walks about, speaks and cries, and
suddenly collapses and dies. The
temperature ranges from 42° to 43°
C. (107.6° to 109.4° F.) and often
even exceeds these levels after death.
2. An acute form of cerebral rheu-
matism is more often observed.
There is likewise high fever; the
delirium commences more quietly,
but after a little time the patient be-
comes agitated, and may have epi-
leptiform seizures, these symptoms
being followed by profound coma and
commonly by death. In a few in-
stances cerebral symptoms are ob-
served with a temperature, not ex-
ceeding 39° C. (102.2° F.). The
pulse rate is proportionate to the
fever and may reach 120 to 140 per
minute. The duration of this form of
cerebral rheumatism is commonly two
or three days, but may be ten to
twelve days. Recovery is rare.
3. The subacute or chronic form of
cerebral rheumatism appears in the
later stages of rheumatic fever and
is ordinarily of a melancholic and
stuporous character. The patients
refuse to speak, even to eat, and are
often harassed with hallucinations.
They may remain in this condition
for months, but the affection ordi-
narily ends in recovery.
Spinal complications have been
described, but their existence hasi not
been proved beyond doubt. The
peripheral nerves may also be affected
during rheumatic fever, but far
oftener such disturbances occur some
time later, as a sequel. Chorea, mul-
tiple neuritis, neuralgia, and sciatica
have been witnessed by trustworthy
observers. During an epidemic
Steiner saw 35 cases with disease of
the peripheral nerves — often in the
distribution of a single nerve — char-
acterized by pain and tenderness.
In 8 of these, swelling of the joints
was not important, though there was
tenderness. Steiner claims that the
nerve pains were due to a perineuritis.^
Complications involving the re-
spiratory organs are not so frequently
observed. Coryza, tracheobronchitis,
and laryngitis may be seen during
the prodromal stage. During the
acute stage the lungs may be affected
either by edema or, more rarely, by
pneumonia, particularly of the migra-
tory form. Rather frequently the
pleurae are involved. A\'hcn the peri-
cardium is affected tlic disease tends
6 RHEUMATISM (LEVISON AND SAJOUS).
to spread to the left pleura, which The affection of the joints them-
consequently is more frequently at- selves may be complicated by sup-
tacked than the right. Rheumatic purative inflammation leading- to
pleuritis is characterized by abun- opening of the articulation and to
dant fibrinous membranes, but scanty pyemia, or ending in ankylosis,
exudation of serous fluid ; it develops In occasional instances involve-
very rapidly and gives rise to the ment of the eye occurs w^ith rheu-
ordinary physical signs of pleurisy matic fever, being manifest in con-
in a very marked degree. Its dura- junctival congestion or, rarely, iritis,
tion varies from three to eight days. Some of the diseases of the eye as-
Sometimes the right pleura is ,at- cribed to the more chronic types of
tacked while left-sided pleuritis is rheumatism are: iritis and episcleritis
undergoing resolution. Peritonitis is — which are very frequent — as well
a rare complication which may be as deep scleritis, keratitis, orbital eel-
associated with serous pleuritis. lulitis, optic neuritis, choroiditis.
Tonsillitis is a frequent manifesta- ocular palsy, glaucoma, and opacity
tion of the prodromal stage, and its of the vitreous (Woodruff),
bacteria are now considered impor- Chronic nephritis and mental dis-
tant etiological factors in the develop- ease are among the possible ultimate
ment of rheumatic fever. sequela of rheumatic fever.
Albuminuria is almost constantly In children cardiac involvement is
observed; acute nephritis and hema- relatively more frequent and impor-
turia may occur. Anuria is a rare tant than in adults and generally
complication ; it may be caused either leads to a fatal termination, promptly
by acute nephritis or by emboli from or ultimately. The onset is generally
an endocarditis. abrupt, sometimes with convulsions.
Cystitis, hydrocele, and orchitis High fever sets in and anemia rapidly
have been mentioned by some as becomes pronounced. Joint involve-
occasional complications. ment is comparatively a less striking
The cutaneous complications in- feature than in adults,
elude roseola, urticaria, erythema DIAGNOSIS. — The diagnosis is
multiforme, herpes facialis, and, more usually easy, the migratory arthritis,
rarely, erysipelas, gangrene, purpura fever, acid sweats, and infrequency
with ecchymotic spots or bullse con- of involvement of joints such as the
taining a serous, bloody, or purulent sternoclavicular, temporomandibular,
fluid. Hemorrhagic complications intervertebral, and sacroiliac being
have also been observed in the form characteristic. The thyroid is often
of melena and metrorrhagia. found enlarged in children, owing ac-
The muscles in the proximity of cording to Sajous, to a defensive re-
the aff'ected joints are always painful action of this organ.
and swollen ; this may also be ob- Enlargement of the thyroid gland
served in the case of muscles more claimed to be a diagnostic sign of
distant from the diseased joints. In rheumatism in children In some
cases it preceded all other manifest
rare instances true inflammation atid
abscesses have been observed in the
muscles. the -rheumatic chain, and in others
signs of the disease; in others it ap-
abscesses have been observed in the peared as the fourth or fifth link in
RHEUMATISM (LEVISON AND SAJOUS). 7
still it was found to persist along The arthritides accompanying such
with established chronic endocarditis conditions as scarlet fever and cere-
after all other rheumatic manifesta- ^rospinal meningitis are commonly
tions had disappeared. J. R. Clemens . ' • ^ vi
(Arch, of Pediat., May, 1910). ^^ septic type, With accompanymg
In children the cardiac phenomena constitutional symptoms of sepsis.
are paramount, but compression of Acutc Osteomyelitis. — This condi-
the left lung by the pericardial exu- ^j^j^ jg characterized by grave con-
date may cause physical signs of g^itutional evidences of sepsis, and
pneumonia in this lung to occur. The . . . . r ^.^
^ , . • ,• 1 ■ 1 v.„ Jo +v,« by especial involvement of the epi-
most characteristic skin lesion is the .^ t" . , ,
so-called rheumatic nodule, which physis and shaft of one of ^ the bones
histologically resembles the mihary articulating at the afifected joint. The
nodule in the heart muscle. These upper extremity of the tibia and the
are usually few, occasionally enor- j^^^^^. ^^^ ^^ ^j^^ femur are the locali-
xnous in number and are found ^ies most frequently affected.
chiefly about the elbows, backs of the ^ , ,• , r
wrists, near the ankles, and over the Gout.—Gout may be discerned from
buttocks. D. Riesman (Trans. Phila. rheumatic fever by the fact that it is
Co. Med. Soc; Med. Rec, Apr. 16, never accompanied by fever of the
1921). same intensity as prevails in the lat-
Secondary Infectious Arthritis. — ter disease; by its predilection for the
Rheumatic fever may be confounded great toe ; by the possible presence of
with the secondary multiple inflam- uratic deposits in various parts of the
mations of joints observed in acute body, and by its special occurrence in
infectious diseases such as scarlatina, the male sex.
cerebrospinal meningitis, puerperal ETIOLOGY. — Rheumatic fever
infection, rubeola, diphtheria, etc., tends to attack especially young
and also with the pseudorheumatic adults, approximately three-fourths
affections of gonorrhea, syphilis, and of the cases occurring between the
tuberculosis. In all these affections asfes of 15 and 35. Infants are almost
the symptoms of the major disorder safe, but no age is entirely exempt,
are present and facilitate diagnosis. The disease attains its greatest fre-
In gonococcal arthritis there is a quency between the ages of 20 and
history of gonorrhea; the joint in- 25 years.
volvement is generally monarticular, Both sexes are liable to the dis-
affecting especially the knee and ease ; among adults, men are perhaps
wrist, and is extremely severe ; con- somewhat more frequently affected
stitutional symptoms are less marked, than women, Init that is probably on
and the joint lesions tend to persist account of their greater exposure to
after the febrile stage. the inclemency of the weather. Be-
In syphilitic pseudorheumatism the tween the ages of 10 and 15 the dis-
joint-symptoms are less intense than ease is somewhat more common in
in rheumatic fever; are not migra- the female than the male sex. An
tory ; show nocturnal exacerbation of hereditary predisposition seems to
pain, and yield rapidly to specific exist in some families. Cheadle,
treatment (though pain is relieved, among 32 consecutive cases, found
as it is in other forms, by the local evidence of heredity in 70 per cent.,
application of methyl salicylate). and, if chorea and erythema be re-
8
RHEUMATISM (LEVISON AND SAJOUS).
garded as forms of rheumatism, in
93 per cent.
Exposure to wet, cold, and abrupt
temperature changes predisposes to
rheumatic fever, which is therefore
commonest in coachmen, laborers,
sailors, and, among women, in washer-
women and domestics. The dis-
ease is frequent only in temperate
climates, and is not observed in
tropics or in the arctic regions.
The exciting cause of the disease is
now considered to be unquestionably
an infection. This view is supported
by the facts that it occurs epidem-
ically, as well as endemically, and
that during epidemics the cases ac-
cumulate in some houses, whereas
other houses are quite spared. Me-
teorological conditions do not appear
to be of great influence on the epi-
demics of rheumatic fever, which
have been observed as well in the
sum.mer as in winter, during dry as
well as wet seasons. The epidemics
vary greatly in intensity and dura-
tion, and occur at irregular intervals.
It is still doubtful whether rheu-
matic fever is the product of one
specific micro-organism or whether
different species act simultaneously
or independently as pathogenic fac-
tors. At all events, the clinical and
pathological features of the disease
clearly show its infectious origin.
That streptococci may produce it has
been shown by a number of ob-
servers, who have not only recovered
these organisms from the blood and
joints of patients, but, like Schloss
and Foster, reproduced lesions sug-
gestive of rheumatic fever in lower
animals. The organism considered
to be most likely the actual exciting
factor, or at least that operative in
the largest proportion of cases, is the
Diplococcus rheiintaticus isolated by
Poynton and Paine, who found it not
only in the joints and blood, but in
rheumatic nodules and the urine, and
with it produced arthritis, valvular
lesions, etc., in rabbits. This organ-
ism is distinguishable neither mor-
phologically, culturally, nor by the
opsonic and agglutinin reactions
(Tunnicliffe) from the Streptococcus
pyogenes, but only by the production of
rheumatic lesions in animals. Poyn-
ton and Paine consider their diplo-
coccus the "only bacterial cause" of
acute rheumatism. Cole believes it
imwarranted, however, to recognize
a distinct variety of streptococcus
because of its property of produc-
ing arthritis and endocarditis, as he
has provoked similar lesions in ani-
mals with streptococci from various
sources. This is in accord with the
present increasing disinclination of
bacteriologists to believe that sharp
lines separate similar organisms into
distinct varieties, and is supported by
the observations of Rosenow (1914)
that the affinity of cocci freshly
isolated from the joints in rheumatism
for the articulations, endocardium,
and often also myocardium and vol-
untarv muscles, which tends to dis-
appear on cultivation, may be re-
stored by passage through animals,
and that other strains of streptococci
under certain conditions may be
made to acquire the properties of
the strains obtained from rheumatic
cases.
Five cases have been published to
date in which the tuberculous nature
of an articular rheumatism has been
established beyond question. The
writer's patient was a girl of 19 who
had had glandular tuberculosis as a
child, and later a tuberculous process
in the lower jaw compelling total re-
RHEUMATISM (LEVISON AND SAJOUS).
section. Twelve days after the op-
eration, moderate fever developed
with multiple acute swelling of joints.
The patient died in a few months
from amyloids. Autopsy showed tub-
erculous nodules in the synovial mem-
branes. Melchior (Mitteil. a. d. Grenzg-.
d. Med. u. Chir., xxii, Nu. 3, 1911).
Cultures of exudate aspirated from
the joints in acute rheumatic arthritis
proved uniformly sterile. Non-hemo-
lytic streptococci were recovered in
blood cultures from less than 10 per
cent, of rheumatic fever patients.
Similar streptococci were recovered
from active endocardial lesions in
only half of the fatal cases. No type
of streptococcus is constantly asso-
ciated with acute rheumatic fever. If
the streptococcus actually is the etio-
logic agent, the infection occurs
through various members of the
viridans group. Swift and Kinsella
(Arch, of Int. Med., Mar., 1917).
Report of an acute case in a girl of
17, with a heart injured by a previous
attack. A general pericarditis with
copious effusion developed, and the
fluid withdrawn by paracentesis showed
numerous minute diplococci, some in
the fluid, many more in leukocytes.
This completely supports the results
of experimentation concerning the
micro-organism of rheumatic fever.
It also indicates that in human rheu-
matic pericarditis with little effusion
but with great thickening of pericar-
dial tissues, the diplococci are shut
in the necrotic areas but imperfectly
destroyed, causing the intractable re-
lapsing cases of childhood. Poynton
(Brit. Med. Jour., Mar. 29, 1919).
As for the portals of entry of rheu-
matic infection, the tonsils demon-
strajjly play an important, if not ex-
clusive, role in this direction. Not
only are the tonsils favorite abodes
of virulent streptococci, and attacks
of sore throat a frequent manifesta-
tion of rheumatism, but ori^anisms
isolated from the tonsils of rheumatic
cases have, with considerable con-
stancy, been observed to induce ar-
thritis and endocarditis when injected
into animals. Permanent cure of a
rheumatic tendency has frequently
followed removal of the tonsils. Ac-
cording to some, the gums, the nasal
mucosa, and the gastrointestinal tract
are also at times sources of infection.
The pleurisy of acute rheumatism
usually yields promptly to the sali-
cylates, but if it is left untreated,
serious lesions may be installed. The
rapid invasion of the pleura, the bi-
lateral involvement, the association
with congestion of the lungs and with
pericarditis without effusion, the com-
plete subsidence without sequels, the
fixity and long duration of the pleural
effusion, its moderate amount, and
the usually mild character of the
pains in the chest are its distinguish-
ing features. J. Mollard and M.
Favre (Lyon med., May, 1917).
Peritonitis, appendicitis, bronchitis,
and pneumonia are sometimes ascrib-
able to rheumatic infection.
Micrococcus rheumaticus takes the
path of least resistance. This may be
an unhealthy throat, absorption from
which frequently gives rise to gen-
eral rheumatic infection, including
peritonitis and appendicitis, directly
through the vascular system. Or it
may be localized in the bronchial
tubes and give rise to pneumonia,
with polyarthritis and endocarditis.
An unhealthy condition of the intes-
tinal wall may excite to activity the
rheumatic agent. Congestion of the
pharynx, palate, and fauces in a child
with a rheumatic family or previous
history, or with a rheumatic facies,
should always be looked on seriously,
and met with local applications of
salicylic acid preparations, together
with sodium bicarbonate, sodium sali-
cylate, potassium chlorate, and aperi-
ents. A 5 per cent, to 10 per cent,
solution of sodium salicylate applied
to the tonsils, palate, and pharynx
protects from further contamination;
a gargle containing 20 to 40 grains
10
RHEUMATISM (LEVISON AND SAJOUS).
(1.3 to 2.6 Gm.) to the ounce (30 c.c.)
is equally efficacious. Decayed teeth
should be filled or extracted, and
the daily use of the tooth-brush and
antiseptic powder should be insisted
on. Inhalation for half an hour, three
times a day, of 10 minims (0.6 c.c.)
of a solution of equal parts of creo-
sote and phenol is the best method
of protecting the pulmonary mucous
membrane. Sodium salicylate, com-
bined with sodium bicarbonate and
rhubarb powder, is by far the best
protective treatment in cases in which
there is any indication of excess of
mucus in the intestine. J. K. Mac-
kenzie (Brit. Med. Jour., June 1,
1912).
A woman of 28 developed subacute
articular rheumatism and endocarditis
five months after an infected abor-
tion. No benefit was procured from
a month or more of the ordinary
measures, including the salicylates,
but after straightening and curetting
the uterus the temperature dropped
to normal and rapid recovery fol-
lowed, signs of mild mitral insuffi-
ciency, however, still persisting. Ar-
ticular rheumatism of puerperal origin
generally settles down in one joint
after a time — the shoulder in the
writer's case — and stays there. Pierra
(Revue mens, de gynec, d'obstet., et
de pediat., Mar., 1914).
PATHOLOGY.— In all cases of
rheumatic fever hyperemia is present
in the joints ; but as these changes are
extremely fugacious it is ordinarily
impossible to demonstrate them at
autopsy. In more advanced cases the
synovia is augrnented and shows mi-
croscopically a great number of poly-
nuclear cells containing globules of
fat, resembling pus-cells. In some
cases the cells are not free, but are
inclosed in a network of fibrin, ap-
pearing to the naked eye as small
flakes. True pus is not found in the
joints except when other infections
have invaded the body consentane-
ously with the specific infection of
rheumatic fever. The synovial mem-
brane of the afifected joints is then
red and swollen, with its capillaries
engorged with blood; the cells of the
synovial membrane tend toward mul-
tiplication, containing 10 to 12 nuclei.
The cartilage is also involved ; its
cells multiply and form oblong cap-
sules containing many secondary
capsules. The macroscopic result of
these alterations is that the cartilage
has lost its natural polish and that
it is finely striated. These patho-
logical changes are common to all
varieties of acute arthritis and are
not characteristic of rheumatic joint
afifection. Mainly because of periar-
ticular involvement, some of the
rheumatic joints, instead of promptly
recovering from the acute process,
mav continue in a condition of sub-
acute or chronic inflammation. The
tendons and even the periosteum may
be attacked, with consequent tender
local thickenings.
The rheumatic alterations of the
endocardium, the pericardium, etc.,
revealed by autopsy present the ordi-
nary signs of an acute inflammation,
but nothing which is characteristic
of rheumatic fever proper. Acute
dilatation of the heart, according to
Lees, is much commoner, even in
slight attacks, than in diphtheria or
influenza. It is, however, far less
dangerous. Although in the rheu-
matic heart there is evidence of fatty
degeneration of the muscle fibers,
with interstitial round-cell foci, the
destruction of the muscle is much
less pronounced than in the diph-
therial heart.
Children are prone to the chronic
or subacute manifestations of rheu-
matism because the chief site of the
RHEUMATISM (LEVISON AND SAJOUS),
11
multiplication of the organism and
the manufacture of the toxins is in
focal lesions outside the blood-
stream, while in adults it is in the
blood itself. The rheumatic nodules
afiford the typical example of local
response to rheumatic infection.
They are usually associated with
grave cardiac mischief, and the more
numerous and the larger they are the
more serious the cardiac involvement.
While present, they prove the per-
sistence of the rheumatic infection.
The lesions found in the heart are
similar in stru"cture to the subcu-
taneous nodules, but their duration is
probably less prolonged. In the meso-
cardium they are found chiefly in the
walls of the left ventricle, especially
near the mitral and aortic valves. In
pericarditis the nodular lesions may
be confined to a small area or scat-
tered all over the pericardium. In
endocarditis the nodules are suben-
dothelial, and are situated mostly at
the upper part of the left ventricle,
especially in the mitral valve. Gos-
sage (Pediatrics, Apr., 1912).
Greater attention should be given
to the various types of acute aneu-
risms and their relations to acute
rheumatic fever. The almost con-
stant presence of some inflammatory
reaction in the ascending limb of the
aorta should be recognized as an as-
sociated conditi®n in this disease.
Klotz (Jour, of Pathology and Bac-
teriology, Oct., 1913).
During the course of rheumatic
fever the blood contains much more
fibrin than normal.
PROGNOSIS.— The prognosis is
rather good as regards life, as very
few cases end fatally (0.3 per cent.).
Usually the disease terminates in two
to six weeks without having caused
permanent injury to the joints in-
volved. Complications, particularly
those involving the heart, are, how-
ever, frequent and often lead to
serious consequences. In some cases
— subacute rheumatic fever — repeated
exacerbations in the joint lesions and
temperature occur before recovery
finally is complete. Hyperpyrexia
and suppurative pericarditis are com-
plications entailing immediate danger,
while endocarditis acts more slowly.
In children the remote prognosis is
always grave, death taking place in
youth or early adult life. The gravid
state also renders the condition more
serious. One attack of rheumatic
fever predisposes to others, and the
ultimate prognosis becomes more
somber in proportion with the per-
sistence of recurrence.
Twenty-three per cent, of acute
articular rlieumatism patients go
through one or more attacks without
any clinical afifection of the heart,
irrespective of the age when first at-
tacked; 22 per cent, develop signs of
carditis in the acute stage, these
signs disappearing during the con-
valescence; 18 to 20 per cent, of the
cases which develop signs of endo-
carditis, not clearing up before pa-
tient leaves the hospital, have no
permanent valvular lesion, the mur-
murs being due to myocarditis, or in-
competence from temporary hyper-
emia of the valves, associated with
dilatation. In 14.5 per cent, of cases
with acute rheumatic endocarditis of
severe type, one or more of the mur-
murs disappear, such murmurs being
due to associated dilatation. Cases
in which the heart is going to recover
completely show signs of such re-
covery within twelve months of the
acute attack, thoug'.i the process may
not be completed till some years
later. Kemp (Quarterly Jour, of
Med., Apr., 1914).
Analysis of 350 fatal cases of
rheumatism. The patients comprised
195 females, 155 males, 250 of them
under the age of 12 years. Rheuma-
tism is at its worst from the sixth to
the twelfth year, and the majority of
deaths occur before the twentieth
year. The percentage of fatal first
12
RHEUMATISM (LEVISON AND -SAJOUS).
attacks in childhood was nearly 23
per cent. In the remaining 100 cases
only 3 deaths were recorded in a
first attack. Pericarditis was found
in 215 of the 250 cases in childhood.
One may expect to detect the friction
sound in at least 80 per cent, of the
cases of recent rheumatic pericar-
ditis; it may be missed because the
pericarditis is localized posteriorly,
very limited in area, or evanescent.
In the 250 fatal cases in childhood,
the mitral valve was damaged in all
^ but 3, the aortic in 102, the tricuspid
in 78, the pulmonary in 6. Among
100 cases in children, 82 died with
evidence of acute carditis. Among
100 older cases, only 9 died of acute
carditis of the childhood type; 14 had
recent endocarditis complicating for-
mer valvular lesions; in 55 the valves
were scarred by old disease, and 22
died of malignant endocarditis. The
usual time for malignant endocarditis
is later childhood, adolescence, and
early adult life. Death from myo-
cardial failure without valvular lesion
occurred in only 3 of the 350 cases.
F. J. Poynton, C. D. S. Agassiz, and
■J. Taylor (Pract, Oct., 1914).
TREATMENT.— In the treatineiit
of rheumatic fever it is of importance
that the patient be placed in a large,
well-ventilated room. He should be
kept in bed, even where the affection
is mild. A flannel nightgown should
be worn, and the patient should sleep
between blankets. The diet should
be limited; during the febrile period
liquid food should alone be given,
with lemonade, carbonated waters,
and milk as beverages. Regularity of
the bowel movements should be
maintained.
Many authors deem it preferable
to commence the treatment by in-
stituting free purgation.
As a specific remedy against the
infection itself, salicylic acid and
combinations containing this drug
have nearly supplanted all others.
Salicylic acid may either be given
pure or in combination with the
alkalies (sodium or strontium salicy-
late). Pure salicylic acid is best tol-
erated when given in capsules each
containing 7j/2 to 15 grains (0.5 to
1 Gm.) ; this dose is to be repeated
fotir, five, or even six times per day,
until the pain is relieved and the tem-
perature falls. When symptoms of
intoxication, viz., ringing in the ears,
nausea, or occasionally, delirium ap-
pear the use of the remedy must be
discontinued for twelve to eighteen
hours, or the dose greatly reduced.
In many cases the pain is very
rapidly subdued by this treatment
and patients who, in the morning
were not able to move, are completely
relieved after a treatment of twelve
hours. In other cases the fever sub-
sides, but the pain and swelling of
one or more joints continue for some
time. Even when all symptoms have
disappeared, it is advisable to con-
tinue the use of salicylic acid for some
time, btit in lesser dose. When the
use of salicylic acid is discontinued
too soon, recurrence is probable.
Many authors prefer the use of
sodium salicylate which is sometimes
given in solution, 1 to 1^ drams (4
to 6 Gm.) or even 2 drams (8 Gm.)
being administered per diem. It has
the same effect on the disease as the
pure acid. By the third day the dose
can generally be reduced to 15 grains
(1 Gm.) every four or five hours.
Other compounds which may be
used are ammonium salicylate, salicin,
and in particular, acetylsalicylic acid
(aspirin) which, being nearly taste-
less, is easily taken with sugar and
water on a spoon or in milk, and is
non-irritating to the stomach, pass-
ing through it unaltered into the in-
RHEUMATISM (LEVISON AND SAJOUS). 13
testine where it is decomposed and passages to a healthy condition.
absorbed in the form of salicylic acid. 1^"^^*^°^ ^"^ thorough cleansing of
the nasal passages, combined with
Inflammation of the throat empha- antiseptic treatment of the nose and
sized as one of the earliest symptoms pharynx, should be a routine item of
of rheumatism and a gargle of 20 antirheumatic treatment; and the
Gni. (5 drams) of sodium salicylate operation of enucleation should be per-
in 1000 Gm. (1 quart) of distilled formed without delay upon all rheu-
water recommended. In the devel- ^^^-^^ children who exhibit chronic en-
oped disease one should endeavor to largement of the tonsils or of the
administer from 6 to 8 Gm. (VA to 2 tonsillar lymphatic glands. W. P. S.
drams) in twenty-four hours to the Branson (Brit. Med. Jour., Nov. 23,
adult; in children 1 Gm. (IS grains) 1912).
per diem if the child is 2 years of j j -i •
^ , , ^ r- /on • ^ -^ The writer recommends daily in-
age or less, and 2 Gm. (30 grains) it . i * o r- /-ic ^.^
.*= ^ -, ', , . , 1, , jections of from 1 to 2 Gm. (15 to
4 or 5. If the drug is not well borne ^ ... r i . xv,^
, , , ,1 ^1 30 grams) of sodium salicylate, ine
in such large doses, these must be ^ '. r n
, - . „ ^ /1T/ 1 1/ solution IS made as iollows: —
decreased 5, 4, or 3 Gm. (1%, 1, or %
drams) until tolerance is produced. Sodium salicylate 5.0 parts.
It should not be given if nephritis Caffeine citrate 0.25 part.
with the presence of casts in the urine Distilled ivater 25.0 parts.
exists, but if the albuminuria is slight q^ ^^-^^^ f^^^^^ 5 ^^ 10 c.c. (1^ to
and there are no casts it may be 2^/^ drams) are given daily. The
given with caution. salicylate must be chemically pure
When the myocardium shows signs ^^^ ^^^ solution kept in the dark,
of being afifected, and the pulse irreg- j^ j^ ^^ special value where medica-
ular, care must be taken not to ^.j^^^ ^^ mouth is not well borne,
depress the heart further. If the p_ y_ Cgj-jiadas (Semana Medica,
endocardium or pericardium are im- -p^^ 23^ 1915).
plicated, the salicylate may be given, t-. ' •. a ^\, a •
^ . , . , , , , The writer recommends the admin-
but It must be withdrawn where there . - v ' 1 ^^ t
. , ,. . , , . r istration of the salicylates by rectum
IS delirium and other signs of cere- . 1 u *t . t
T . or intravenously where the stomach
bral excitement. In pregnancy it • 1 n- ^u
.... is rebellious or the case requires
must be given with caution. Aspirin • 1 .• -ri • 4.
. , rr ■ 1 .1 1- r <. rapid action. The intravenous injec-
is less efficacious than the salicylates, '^ r m * on • /ha ^-^
, , , , , . . ,.-,,, tions are of 10 to 20 grains (0.6 to
and should be given in divided doses 1 o r- \ • oa <. 1 ..• a
- 5' .,- .r • X 1.3 Gm.) in 20 per cent, solution and
up to 1 to 3 Gm. (15 to 45 grains) . / Z ^- • * *
^ , ,. ., given two or three times m twenty-
focn '''rc:n°r"''^'7x/''^.''?r ^ fo"^ hours if necessary. Rectal in-
(0.50 to 1.50 Gm.-7/. to 23 grains) ^^^.^^^ ^^^ ^r.i.rr.A, and as much
also has its uses. If these remedies. or ,q \ k •
r . , J • as 2 drams (8 c.c.) may be given,
in succession do not produce im- •,, 1 c • • r^ \ : *4«^*,„...
, . J with 15 minims (1 c.c.) of tincture
provement, they can be combined . ^ a ■ ^ \ t,^„^c.
^ . . , ' o J- 1- 1 .^ of opium, repeated in twelve hours,
with advantage: Sodium sahcylate, n r \ ^ 4. 1 ^ ,„
^^^ ^ ,. ^ . . . . rtie r- The alkaline treatment may be com-
025 Gm. (4 grains); aspmn, 015 Gm. ^.^^^ ^.^^^ ^^.^^ ^^^^ ^^^.^.^ .^ ^^_ ^^
i2}i grains); pyramidon. 0.15 Gm ^O- grain (0.6 to 1.3 Gm.) doses may
(2y4 grains). In cases complicated ^^ ^.^^^^ ^^^^^ ^^^ ^^^^^ ^j^^^ p^j^^
with nephritis, cupping of the loins, .^ ^^^ .^.^^^^ j^^^ diminished. The
milk diet, and laxatives are indicated. ^^^^ combination internally is am-
Lemoine (Gaz. des pract., vol. xix, monium salicylate, 5 to 10 grains
1912). (0.3 to 0.6 Gm.), with phenacetin, 1
The commonest avenue of rheu- to 2 grains (0.06 to 0.13 Gni.), and
matic infection is the tonsil, and next caffeine citrate, 1 grain (0.06 Gm.)
to it the nose. The first essential of in capsules, every two hours. Bever-
rational treatment of rheumatic in- ley Robinson (Med. Rec, Jan. 1,
fection is restoration of the upper air 1916).
14
RHEUMATISM (LEVISON AND SAJOUS).
The first essential is the thorugh
searching out and removal of all foci
of chronic infection and the prepara-
tion of an autogenous vaccine from
organisms isolated from such foci or
from the urine if foci cannot be
definitely located. The vaccines
should be given in ascending doses,
every week or ten days, adjusting the
dose so as to secure a slight arthritic
reaction. After improvement has ad-
vanced, the intervals between doses
may be lengthened. The treatment
should be continued for a year or
more. M. J. Rowlands (Lancet, Jan.
15, 1916).
Also serviceable where the simple
salicylates are not well borne is salo-
phen, which is gradually decomposed
in the bowel into salicylic acid and
acetylparamidophenol, and may be
given in doses of 15 grains (1 Gm.)
every three hours, preferably in con-
junction with sodium bicarbonate, 10
grains (0.6 Gm.) three times a day
(W. H. Flint). This drug has also
been recommended for use late in the
course of the disease, when the acute
fever has been mastered with salicylic
acid. Oil of wintergreen may also be
substituted for the other salicylates
in doses of 20 minims (1.25 c.c), but
is not unirritating to the stomach.
Salicin. has a bitter taste, is much
less nauseous than sodium salicylate,
and can be conveniently given dis-
solved in hot water. It only yields 43
per cent, of its weight of salicylic
acid, and hence the amount required
is at least double that of sodium sali-
cylate—20 to 30 grains (1.3 to 2 Gm.)
every hour or two hours until 1 ounce
(30 Gm.) has been given, and then
smaller doses according to the cir-
cumstances. Acetylsalicylic acid is
very active and has a marked anal-
gesic effect. It cannot be prescribed
with alkalies, which decompose it,
and hence it is apt to bring on nausea
and vomiting if given continuously.
Methyl salicylate is also very apt to
irritate the gastric mucous membrane,
but in 10- to 20- minim (0.6 to 1.25
c.c.) doses up to 60 or 90 minims
(3.75 to 5.6 c.c.) per day, given in
emulsion, or on sugar, or in milk, it
acts powerfully, and externally ap-
plied it is unrivalled for its analgesic
action. Sodium benzoate has the
same specific effect as the salicylate,
but acts less powerfully. On the
other hand, it is practically non-
poisonous and has no disturbing side-
effects. It can be given in 20-grain
(1.3 Gm.) doses every two or three
hours with satisfactory results in
cases of uncomplicated rheumatic
fever, but its practical usefulness is
merely as a substitute for the more
powerful salicylate, when the latter
cannot be tolerated. Profuse per-
spirations and skin eruptions are in-
conveniences which frequently follow
salicylates. They are also often
deemed to act as heart depressants,
but this is not borne out by exact
observations. With large doses (250
to 400 grains— 17 to 27 Gm.— per
day), such as are sometimes given
with the idea of thoroughly destroy-
ing the infective germ, vomiting fre-
quently occurs, and it is possible not
only to seriously depress the nervous
system, but to bring on a dangerous
condition of acidosis. This can be
prevented, to some extent at least, by
giving about twice the amount of
sodium bicarbonate with each dose
of sodium salicylate, and taking care
at the same time to avoid constipa-
tion. But in an ordinary case of
moderate severity 15 to 20 grains (1
to 1.3 Gm.) of sodium salicylate every
three or four hours form a sufficient
dose. The joint pain and tempera-
ture begin at once to be favorably
affected, the former subsiding in from
twelve to twenty-four hours, and the
latter within forty-eight hours. The
pulse and respiration fall with the
temperature, and the joint effusion
is absorbed in two or three days.
The course of events usually resem-
bles a crisis, though sometimes a
lysis. If the temperature does not
settle satisfactorily each dose may be
RHEUMATISM (LEVISON AND SAJOUS).
15
increased, or one large additional
dose of 40 to 60 grains (2.6 to 3 Gm.)
may be given on one or on several
daj's in succession. Additional ab-
sorption of salicylic acid may be
brought about by applying a dressing
of methyl salicylate on lint to the
affected joints. Where the rheumatic
infection locates itself chiefly in the
fibrous tissues, the condition generally
in time yields to large doses of sali-
cylates, along with free local applica-
tion of methyl salicylate. When these
rheumatic indurations are quite re-
cent, potassium iodide and small blis-
ters exert a marked deobstrucnt effect.
Massage is even more effectual.
Stockman (Pract., Jan., 1912).
The writer nearly always used as-
pirin and sodium salicylate jointly,
administering as mucli as 10 or 15
grains (0.6 to 1 Gm.) of sodium sali-
cylate and 5 to 10 grains (0.3 to 0.6
Gm.) of aspirin every two hours al-
ternately. W. J. Judy (W. Va. Med.
Jour., Aug., 1912).
Sodium salicylate with sodium bi-
carbonate, 1 part of the former with
2 parts of the latter, is a most ef-
fective antirheumatic, if the dose is
gradually increased to a sufficient
extent. If, when vomiting or tinnitus
occurs, the medicine is suspended
for a few hours, the unpleasant symp-
toms will usually pass away, and the
dose can later be raised to a consid-
erably larger amount without causing
their recurrence. In a rheumatic at-
tack it is often desirable to increase
the amount of salicylate to 150 or 200
grains (10 to 13 Gm.) per day, with
double the amount of sodium bicar-
bonate, given in 10 doses. It is im-
portant to prevent constipation, to
keep the urine slightly alkaline and
to stop the drug when vomiting or
other symptoms due to salicylate
occur. Lees (Brit. Med. Jour., Oct.
12, 1912).
The nodes call for intensification of
the treatment. In 1 of 3 cases in
children of 11 and 13, salicylates in-
travenously and by the mouth were
kept up for 7 montiis with slow im-
provement and final recovery, even
the heart functioning normally and
the child increasing 22 pounds in
weight. The nodes, though extremely
numerous, persisted for 3 months. A
girl of 11 years was given orally in 4
months 130 Gm. (4% ounces) of the
salicylate besides intravenous injec-
tions up to a total of 9.5 Gm. (2%
drams). Though the treatment was
ordered discontinued, the parents
continued it for 3 months longer (32
injections by the vein) with a total of
16 Gm. (4 drams), perfect recovery
resulting. Navarro (Rev. de la Asoc.
Med. Argentina, Apr.-June, 1920).
Nothing certain is known of the
manner in which saHcylic acid and its
compounds influence the rheumatic
infection. Possibly salicylic acid has
a specific action on the micro-organ-
isms; it" is a reliable, but not an in-
fallible, remedy, relieving the joint
condition, shortening the disease,
diminishing the likelihood of relapse,
and probably protecting the heart.
Some cases are rebellious to its
action. Some patients do not toler-
ate it, vomiting being induced. It
may then be administered by inunc-
tion or enema. For inimction a 20
per cent, ointment of salicylic acid
or of methyl salicylate may be used.
For administration by enema Erlan-
ger uses the following formula: —
R Sodii salicylatis. 3iss to ij (6 to 8 Gm.).
Tincturcc opii .. Tri.lxxv (5 c.c).
Aqua f^iiiss (100 c.c). — M.
This should be injected, after pre-
liminary cleansing of the bowels, at
body temperature, and should be re-
tained as long as possible in the in-
testines.
Intrarectal administration of sodium
salicylate recommended in refractory
cases of acute and subacute rheumatism.
The salicylate enema is given immedi-
ately after a cleansing soapsuds en-
ema, and is administered with a
16
RHEUMATISM (LEVISON AND SAJOUS).
Davidson syringe and a rectal tube
inserted 6 to 8 inches. First dose
in men is usually 8 to 10 Gm. (2
to IVi drams), in women 6 Gm.
(1^2 drams), incorporated in 120 to
180 c.c. (4 to 6 ounces) of plain or
starrh water, with 1 to 1.5 <:.c. (16 to
24 minims) of opium tincture. The
dose may be repeated within 12 hours,
but usually a daily enema suffices, with
doses increasing from 30 to 50 per
cent, daily until the limit of tolerance
is reached. L. G. Heyn (Jour. Amer.
Med. Assoc, Sept. 19, 1914).
Where the effects of salicylates in
acute rheumatism are not as expected,
the so-called "alkaline treatment" may-
be instituted, or, the two forms of
treatment may be combined — a pro-
cedure especially useful in children.
This consists in the administration of
20 or 30 grains (1.25 or 2 Gm.) of
potassium bicarbonate, citrate, or
acetate, or sodium bicarbonate every
two or three hours for the first few
days, or until the urine is alkaline.
Luff advises combined salicylic and
alkaline medication in all cases of rheu-
matic fever. He gives 20 grains (1.25
Gm.) of sodium salicylate and 30
grains (2 Gm.) of potassium bicarbo-
nate every two hours until pain is re-
lieved, then every four hours till the
temperature has fallen to normal. Fif-
teen grains (1 Gm.) of the salicylate
and 20 grains (1.25 Gm.) of the bicar-
bonate are then given every four hours
until all joint symptoms have disap-
peared, and after this three or four
times a day for a fortnight longer.
Comparative statistics show that pa-
tients do not recover any more quickly
under salicylates than with the alk-
aline treatment, but with the salicylate
treatment pain is sooner relieved.
Heart complications are not any more
common when treating with the salicy-
lates. J. L. Miller (New York Med.
Jour., July 4, 1914).
Intravenous and subcutaneous injec-
tions of salicylates have been recom-
mended by several observers, both to
avoid upsetting the stomach and for
prompt, powerful effect. Behr lauds
the following combination for intra-
venous use, originated by Mendel : —
IJ Sod'n salicylatis ... 3ij (8 Gm.).
Caffeince sodiosal-
icylatis (N. F.) . . 5ss (2 Gm.).
Aqiice stcril(c, q.s. ad f5iss (50 c.c). — S.
Methyl salicylate, or artificial oil
of wintergreen, is recommended for ex-
ternal use in rheumatic fever. It is a
volatile fluid of an aromatic odor. The
affected joints are to be painted with
the drug and enveloped with some im-
pervious material. Experience has
shown that the salicylic acid contained
in methyl salicylate is absorbed through
the skin. It is also chemically demon-
strable in the urine. It removes the
pain and reduces the temperature.
In acute rheumatism and allied con-
ditions such as acute rheumatic sci-
atica, the result of thyroid treatment
may be striking. Tompkins (So. Med.
Jour., Dec, 1910).
Hypodermic injection of salicylates
advocated, for the purpose of secur-
ing prompt action and avoiding di-
gestive disturbances and toxic symp-
toms. In acute rheumatic infection
of joints, heart, pericardium, pleura,
and central nervous system (chorea),
inject 10 c.c. (2^/2 drams) of 20 per
cent, sterile solution of fresh sodium
salicylate per 100 pounds of body
weight. First disinfect a spot out-
side of the median line of the thigh
with fresh iodine tincture. Through
this inject sterile cocaine solution (^
grain — 0.008 Gm. — in 30 drops) under
the skin, and after waiting fully fif-
teen minutes inject salicylate solu-
tion under the same spot. This causes
general improvement within three
hours. Repeat the injection every
twelve hours. In severe cases, with
many seats of involvement, increase
RHEUMATISM (LEVISON AND SAJOUS).
17
the dose to 15 c.c. (^ ounce) per 100
pounds weight. In chronic cases, in-
ject every twenty-four hours 10 c.c.
(2^ drams) per 100 pounds of the
following: Salicylic acid, 10 Gm. (2^
drams); sesame oil, 80 Gm. (2%
ounces); pure alcohol, 5 Gm. (75
drams); gum camphor, 5 Gm. (75
grains). This is to be sterilized
before adding the alcohol, and after-
ward excluded from contact with
air, to avoid evaporation of alcohol.
The effect of the injection in chronic
cases is obtained more rapidly when
multiple localizations of the rheu-
matic process are present than when
one joint is affected. In the former,
pain and stiffness usually improve
after the first injection; in the latter,
after the third. The addition of
camphor (from 5 to 20 per cent.) was
found beneficial in stimulating the
heart when the pericardium or the
endocardium was involved. Seibert
(Med. Rec, Mar. 11, 1911).
Magnesium sulphate, administered
by intramuscular injection, by mouth,
and applied externally, found val-
uable in cases of acute articular
rheumatism. Intramuscular injec-
tions of 4 c.c. (1 dram) of a sterilized
25 per cent, solution of the salt, all
aseptic precautions being observed,
brought rapid relief from pain, re-
duced stiffness and swelling, and
sometimes considerably lowered tem-
perature. No pain followed the
injections. In some instances purga-
tion resulted. Injections were re-
peated on succeeding or alternate
days. A saturated solution was ap-
plied to the inflamed joints with
benefit. The intramuscular injections
are recommended for cases in which
salicylates fail to give results. A. B.
Jackson (N. Y. Med. Jour., June 24,
1911).
In many cases where the salicylates
failed in their action, or were not
well borne, coUargol in the form of
an intravenous injection, 2 c.c. (32
minims) of a 5 per cent, solution, or
an enema of 50 c.c. (1% ounces) of
a 5 per cent, solution, gave excellent
results. In giving the intravenous in-
jection the heart must be normal, as
there is a sudden rise of temperature
to 40° C. (104° F.); the injection per
rectum is not followed by this rise in
temperature, and the results are about
the same. Junghaus (Deut. med.
Woch., Nov. 1, 1912).
Case of rheumatic fever in which,
although sodium salicylate appeared
at first to be giving excellent results,
the pain, joint swelling, and fever
later returned, the heart rate in-
creased, and the first sound became
muffled. Ten days' energetic treat-
ment with the salicylate proving com-
pletely ineffectual, 8 Gm. (2 drams)
of antipyrin were administered in
two days, and the salicylate in daily
doses of 5 Gm. (75 grains) resumed
immediately after. The fever was
thus rapidly overcome and convales-
cence entered upon. The return to
a massive dose of the salicylate after
the two days' intermission seemed the
essential factor in the benefit ob-
tained. Interrupted administration of
salicylates has already been recom-
mended for obstinate cases, and anti-
pyrin seems especially suitable for
use during the intervals. Roch (Rev.
med. de la Suisse romande, Feb.,
1913).
The writer's experience with the
intravenous administration of sodium
salicylate comprises 12 cases of artic-
ular rheumatism of various degrees
of severity, in which about 130 injec-
tions were used. The two most im-
portant points to be observed in the
giving of the injections were found
to be: (1) to use only a very fine,
sharp needle, so that the trauma to
the vein wall may be as slight as pos-
sible; and (2) to have the solution
fresh and made with chemically pure,
crystalline sodium salicylate. The
stock solution was made by dissolving
10 Gm. (214 drams) of C. P. crystal-
line sodium salicylate in 50 c.c. (1%
ounces) of distilled water, freshly
sterilized by boiling. The drug was
weighed and handled as aseptically as
possible and the solution, after being
made, not subjected to further sterili-
zation. The solution should be per-
8—2
18
RHEUMATISM (LEVISON AND SAJOUS).
fectly colorless and, if protected from
the light, was found to keep for
several days. L. A. Conner (Med.
Rec, Feb. 21, 1914).
Attention to the joints in rheu-
matic fever is of great importance.
They should be placed at complete
rest by means of splints, and may
also with advantage be wrapped in
cotton or in cloths wet with a satu-
rated solution of magnesium sul-
phate or with lead water and lauda-
num. Methyl salicylate, as already
mentioned, may also be applied.
Bourget recommends the following
ointment : —
^ Acidi salicylici gr. xlv (3 Gm.).
Olei tcrebinthince ... mxlv (3 c.c).
Adipis lance hydrosi,
Adipis bcnzoinati. .3.3. 5v (20 Gm.).
Fiant unguentum.
Sig.: To be applied, and covered with
absorbent cotton and an impervious ma-
terial.
Baker finds the following collodion
useful in relieving pain : —
I^ Phenylis salicylatis 3j (4 Gm.).
Mthcris f5i (4 c.c.) .
Collodii ill (30 c.c).
M. Sig.: To be painted on the affected
joints twice daily or oftener.
Arendt praises a formula contain-
ing ichthyol : —
R Ichthyolis 3iiss (10 Gm.).
Alcoliolis dilttti fSiiss (10 c.c).
Aqu<u destillatcc f3x (40 c.c). — M.
Robinson has found the following
ointment so efficient as to permit of
dispensing with internal treatment
altogether : —
B Mentholis 3j (4 Gm.) .
Methylis salicylatis .... f3j (4 c.c).
Acidi salicylici 3ij (8 Gm.).
Alcoholis q. s. ad fjj (30 c.c).
M. Sig.: Paint jomts briskly with
camel's-hair brush, cover with absorbent
cotton and oiled silk, and bandage snugly
but not tightly.
When the epidermis begins to peel
an emollient ointment should be sub-
stituted for a day or two.
Sixteen cases of acute rheumatism
treated l)y typhoid vaccine, used only
as a standardized foreign protein.
Sixteen minims (1 c.c.) were given in-
travenously daily until a cure had
been obtained. The treatment is
justifiable where apical abscesses, in-
fected tonsils, gall-bladder, appendix,
or genitourinary tract can be demon-
strated and removed, and in those re-
fractory to other treatment. Lyter
(Jour. Amer. Med. Assoc, Jan. 5, 1918).
Excellent results from hypodermic
injections, once daily, of 150 c.c.
(5 ounces) of a solution of 7 Gm.
(108 grains) of sodium chloride and
10 Gm. (155 grains) of sodium sul-
phate in a liter (18 ounces) of water.
It is seldom necessary to give more
than 3 or 4 doses to obtain marked
improvement. S. L. Brian (La Sem-
ana Med., June 6, 1918).
Subcutaneous injection of oxygen
systematically used in thousands of
patients with rheumatism, mostly
subacute and chronic. It is a power-
ful adjuvant to other measures. The
writer usually injects 100 c.c. (3%
ounces) at the site of the pain, some-
times injecting all the larger joints at
1 sitting, using up 2, 4, or more liters.
An elderly woman with chronic nodu-
lar rheumatism for two years in hands
and knees was relieved of all pain
and inflammation by 8 injections.
The oxygen was injected into the
dorsum of the hands and massaged
into the fingers. Zabaleta (Siglo med-
ico, Aug. 10, 1918).
In subacute and chronic rheuma-
tism several writers advise the use of
a Z2) per cent, ichthyol ointment or a
20 per cent, ichthyol-glycerin solu-
tion, aided by ichthyol and iodides in-
ternally. Salicylic cataphoresis has
also 1)een used.
Report of rapid cure of acute rheu-
matism after intra-articular injections
of sodium, salicylate by the catapho-
retic method. Similar cases reported.
RHEUMATISM (LEVISON AND SAJOUS).
19
Wullyamoz (Brit. Med. Jour., Aug.
13, 1910).
Occasionally cases of rheumatism
are met with in which the pains do
not yield to sodium salicylate and yet
promptly yield to acetylsalicylic acid
(aspirin). Internal administration of
salicylates frequently fails to give re-
lief to the pain experienced about the
fibrous tissues, notably under the
heels in patients who have had a pre-
vious attack of acute articular rheu-
matism. In such cases the local use
of oil of wintergreen, 1 dram (4 Gm.)
to an once (30 Gm.) of lanolin, will
generally give relief. The same ap-
plies to the pain accompanying acute
rheumatic pleurisy or pericarditis.
For painful conditions about fibrous
structures the addition of from 3 to
5 grains (0.2 to 0.3 Gm.) of potassium
iodide to the sodium salicylate often
proves beneficial. Joint effusions of
rheumatism are responsive to salicy-
lates in proportion to the absence of
mechanical irritation by movement.
In erythema nodosum local treatment
with oil of wintergreen brings marked
relief of the pain and probably a
shortened duration of the attack. A.
F. Voelcker (Clin. Jour., Aug. 16,
1911).
The writer recommends in the
treatment of light attacks of rheuma-
tism, as well as in sciatica, gout, and
neuralgias in general, the following: —
Acidi salicylici 10 Gm. (2^ dr.).
Olei terehinthin.(c ... SO Cc. (1% oz.).
Sulphuris pnecipitati. 40 Gm. (l^/^ oz.).
M. ft. lotio.
The salicylic acid is dissolved in 10
Gm. (2^ drams) of the turpentine,
the sulphur mixed with the remainder,
and the two portions then mixed.
After the preparation has been ap-
plied to the skin, it is covered with a
layer of impermeable tissue held by
a bandage. When the dressing has
been allowed to remain for three or
four days the skin, on its removal,
will be found to have become de-
tached from the deeper layers. Un-
less the patient is sensitive, the
preparation may be applied again.
Otherwise, it is well to use a zinc
paste. Scharff (Therap. Monats.,
Feb., 1912).
Excellent results obtained by apply-
ing externally a mixture of 2 parts
of ground camphor and 1 part of
phenol, adding 5 per cent, alcohol to
the mixture. The result is an oily
fluid, sparingly soluble in water, and
free from caustic action. Only very
delicate skins feel a slight smarting.
It seems to be especially toxic to
streptococci. V. Chlumsky (Zent-
ralbl. f. inn. Med., Mar. 9, 1912).
In children the salicylates, also
hold first place. The dose must l>e
90 to 150 grains (5.8 to 9.7 Gm.) in
divided doses at short intervals dur-
ing the first 24 hours, with a nearly
equal amount of sodium bicarbonate.
Later the dose may be lessened. If
the case responds at all the fever
and pain subsides in 48 hours. In
some cases morphine must be given.
The joints may b-e wrapped in ■ cot-
ton or local applications of lead water
and laudanum, magnesium sulphate
or oil of gaultheria made. A splint
may be applied. Abundance of water,
lemonade and orangeade should be
given. The food should be in the
form of milk or milk products,
cereals and broths. Rarely, a stock
vaccine has proved beneficial. Dis-
eased tonsils should be removed.
Riesman (Trans. Phila. Co. Med. Soc;
Med. Rec, Apr. 16, 1921).
Where the joint pain remains
severe in spite of salicylates, Dover's
powder may be ^8:iven ; or, particu-
larly at nig^ht, an injection of mor-
phine may become necessary.
The complications of acute articu-
lar rheumatism should be treated ac-
cording to the nature and the indi-
cations of each. Hyperpyrexia and
cerebral rheuinatism may necessitate
the application of tepid and even
cold baths combined with large doses
of antipyretics; the cold baths or cold
pack should be begun as soon as the
20
RHEUMATISM (LEVISON AND SAJOUS).
temperature starts to rise quickly
above 105° F. (40.5° C), otherwise
considerable danger to life may be
entailed. Upon the advent of endo-
carditis the use of the ice-bag or pre-
cordial blistering should be availed
of, and digitalis may have to be em-
ployed.
A persistently high pulse rate in
acute articular rheumatism is always
to be regarded as indicative of myo-
cardial involvement, and as long as
it continues absolute rest is essential.
Rest in bed should be persisted in as
long as six months to a year if the
physical signs indicate that the heart
has not recovered completely. Dur-
ing the acute stages of the disease
the pain may make the patient very
restless. Under these circumstances
an ice-bag may be applied over the
heart, and sleep should be obtained
by the use of morphine, since the
other hypnotics do not sufficiently re-
lieve pain to permit rest. If the
patient has not much pain, but is
nevertheless restless, the bromides
are of no value. When the heart re-
mains persistently weak, and suffi-
cient time has elapsed for inflamma-
tory processes to quiet down, minute
doses of digitalis and arsenic, contin-
ued over a long period, are often of
value. Turnbull (Austral. Med. Jour.;
Therap. Gaz., Nov. 15, 1911).
When the fever declines, but one
or more articulations remain swollen
and painful, it has been recommended
to employ bandaging for some time.
Also, baths in hot water or, better,
hot-air baths, will in many cases
bring relief. Massage is likewise a
valuable measure.
Iron is usually a useful remedy
during convalescence, in view of the
rapid anemia induced by the disease.
With it may be coupled quinine and
strychnine. Arsenic may also be of
value. A generous diet should be
allowed.
In rheumatic conditions associated
with anemia and in sore throat of
rheumatic origin, following mixture
recommended: Dissolve 1 dram (4
Gm.) of sodium saUcylate in 2 ounces
(60 c.c.) of water. Add liquor ferri
perchloridi, plus an ounce of water,
giving dark-purple mixture. Then
add 1 dram of potassium bicarbonate
dissolved in 1 ounce (30 c.c.) of water,
and fill up bottle to 8 ounces with
water. Drinkwater (Liverpool Med-
ico-Chir. Jour., July, 1911).
No treatment has been found able to
prevent surely the complications or re-
currence, but most authors agree that
the use of salicylates in sufficient doses
continued for some time after the re-
turn of normal temperature gives the
best results in both respects.
Cases showing the possibility of
treatment with colloidal sulphur, of
cutting short an oncoming chronic
rheumatic state following attacks of
acute rheumatism. The patient was
completely relieved, resuming his oc-
cupation in three months, in spite of
several interruptions in the treatment.
The solution of colloidal sulphur em-
ployed contained 0.2 Gm. (3 grains)
of sulphur to every 15 c.c. (^ ounce),
and was given in doses of 1 teaspoon-
ful before breakfast and supper, grad-
ually increased to 1 tablespoonful.
The solution was rendered palatable
with sugar and an 'aromatic prepara-
tion. Sodium salicylate, having no
efifect on the pain or in preventing
recurrence of subacute attacks, may
be advantageously replaced by qui-
nine sulphate in the dose of 5 grains
(0.3 Gm.) twice a day. A. Robin and
L. C. Maillard (Bull, de I'Acad. de
Med., Nov. 25, 1913).
The writer regards all arthritic in-
flammation as microbic, and 90 per
cent, of the cases are due to strepto-
cocci. Acute inflammatory rheuma-
tism, chronic , articular rheumatism,
and arthritis deformans are but dif-
ferent manifestations of one cause,
modified by individual susceptibility,
both constitutional and local, and
RHEUMATISM (LEVISON AND SAJOUS).
21
duration of disease. He reports suc-
cessful treatment of chronic rheuma-
tism by means of autogenous vac-
cines. The preferable source for
these is the pharynx. The benefit
from vaccine ranged from total cure
in the mild cases, to disappearance
of all symptoms except transitory
slight stiffness in the most severe.
Greeley (Med. Rec, June 13, 1914).
Where a case persists over many
weeks, a focus of infection in the ton-
sils, nasal sinuses, ears, or elsewhere in
the body should be sought. Tonsillec-
tomy may be required.
The writer deprecates the general
tendency to refrain from operating on
inflamed tonsils associated with acute
joint involvement. There may be
greater danger in deferring operation
too long. If the tonsils are the source
of infection, their continued presence
increases the danger of secondary in-
volvement of the heart. Tonsillec-
tomy is indicated as soon as the acute
tonsillar inflammation sul)sides. Sali-
cylates in large doses should be used
to allay joint pains before operating.
With intensive salicylic treatment
the writer also gives sterile milk sub-
cutaneously, thus producing hyper-
emia of and exudation over the in-
volved structures. The rheumatic
process is controlled in a few days.
Of 70 cases treated, none developed
pericarditis, and but 2 a cardiac lesion.
The treatment succeeds where sali-
cylate treatment alone seems ineffec-
tive. Endocarditis is favorably influ-
enced by intramuscular injections of
10 c.c. (2;/ drams) of sterile milk.
A. Edelmann (Miinch. med. Woch.,
Dec. 18, 1917).
Nephritis plays the chief role in
causing senile rheumatism. If the
patient is robust the writer gives
Seidlitz mixture or magnesium citrate
before breakfast; if frail, a compound
cathartic pill at bedtime. Cabinet
baths once or twice a week are very
beneficial. Salicylates irritate the
kidneys. Heroine usually relieves
the pain in acute cases. Superheated
air at 130°, 180°, or 200° C. is applied
to cases with a tendency to defor-
mity. Sodium succinate, 10 grains
(0.6 Gm.) every three hours, is often
of great value. Senile rheumatism
improves on exercise. M. W. Thewlis
(Med. Rev. of Reviews, June, 1918).
MUSCULAR RHEUMATISM.
Muscular rheumatism, or myalgia, is
an affection of the muscles and the re-
lated fasciae, causing pain and stiffness,
which usually disappear after some
days. It sometimes assumes chronicity,
being then accompanied by the forma-
tion of fibrous bands and nodules in
the muscles.
SYMPTOMS.— The principal symp-
tom is pain, which may be spontaneous
or caused by movements or pressure of
the diseased parts. The pain in some
cases remains limited to the muscles
first affected, but sometimes it suddenly
disappears from these and attacks an-
other group of muscles. Slight fever
sometimes attends the affection. The
symptoms vary according to the
muscles affected. In rheumatism ot
the intercostal muscles — pleurodynia —
(sometimes with involvement of the
pectorals or the serratus magnus),
breathing is painful and the disease
may be confounded with pleurisy.
Localized tenderness may exist over
the involved muscles. When the mus-
cles of the abdominal wall are affected,
there is excessive tenderness to pressure,
and the symptoms may resemble those
of acute peritonitis ; but the absence of
fever is of great value as a diagnostic
sign. Rheumatism of the muscles of
the back occasionally gives rise to opis-
thotonos, and suspicion of spinal men-
ingitis may arise. Lumbago, or in-
volvement of the lumbar muscles, may
completely incapacitate the patient, and
may simulate disease of the sacroiliac
joint, vertebrae, etc. Rheumatism of
22
RHEUMATISM (LEVISON AND SAJOUS).
the muscles of the neck causes stiffness,
and, when the muscles of one side only
are affected, rheumatic torticollis (wry-
neck) is produced. The sternomastoid
muscle may become prominent as a
tense, tender cord, and rotates the head
toward the involved side.
Pleurodynia can be distinguished
from pleuritis by the absence of a fric-
tion rub, and from intercostal neuralgia
by the absence of the characteristic
tender or painful spots, and by the fact
that the pain does not strictly follow
the course of the intercostal nerves.
The acute form of muscular rheuma-
tism passes away in a few days. The
chronic form may continue for weeks
and months and often provokes forma-
tion of new connective tissue, with its
consequences — stiffening of the muscles
and contractures. Sometimes small
fibrous bands and nodules are formed
in the muscles and give rise to much
pain and tenderness.
Rheumatism of the muscles is in
some cases complicated Avith myositis,
which may be general or localized, —
limited, for instance, to the muscle of
the heart.
Muscular rheumatism is a danger-
ous diagnosis for a conscientious
physician to make. The correct diag-
nosis may be either aortic aneurism,
cancer of the pleura, tabes, osteomye-
litis, spondylitis deformans, bone tu-
berculosis, syphilitic periostitis, lead
poisoning, morphine habit, alcoholic
neuritis, trichinosis, gonorrheal sep-
sis, onset of an acute infection
(typhoid, influenza, variola, arterior
poliomyelitis, meningitis), intestinal
autointoxication, sacroiliac joint re-
laxation, local disease of muscle,
hematoma due to trauma, hematoma
following vascular change (as in ty-
phoid, sepsis, jaundice), muscular
cicatrices following fibrous myositis,
atheroma of arteries in muscle (as in
intermittent claudication), muscle ab-
scess, infarct, gumma, echinococcus
cyst, or new growth. The diagnosis
of muscular rheumatism must be
made by exclusion. M. A. Rabinowitz
(N. Y. Med. Jour., July 12, 1913).
ETIOLOGY AND PATHOLOGY.
— Overwork, especially when combined
with exposure to cold and dampness,
has always been considered as the com-
mon cause of rheumatism of the mus-
cles. Many persons are very sensitive
to draughts, and readily develop the
affection, especially upon sudden cool-
ing after physical motion sufficient to
cause perspiration. The disease com-
monly occurs after the thirtieth year,
but is also observed before tliat aee.
The disease is very liable to recur in
muscles which once have been affected
by it; especially in the muscles of the
neck.
In all probability the muscular form
of rheumatism, like the articular form,
is caused by micro-organisms, but their
presence in the affected muscles
has as yet not been proved by direct
observation.
The pathological condition pro-
duced is believed to be chiefiy an in-
flammation of the fibrous investment
of the muscle fibers, the attachments
of the muscles to periosteum, and the
fasciae surrounding them. Stress is laid
by some on disturbance of the sensory
nerve endings in the muscles.
J. Madison Taylor states that fibro-
myositis is often a common factor in
many states variously named where
either pain, tenderness, or lameness is
a feature. It may not be painful,
merely a latent tenderness. It is
often superadded to other causes of
disability, complicating and obscuring
them; is only to be differentiated by
expert tactile exploration ; the condition
should be remedied to permit exact
RHEUMATISM (LEVISON AND SAJOUS).
22>
diagnosis. The site can usually be
located and evaluated by alterations
in the local density, tension, mobility
or restriction of motion. Nodes are
often minute but characteristic.
Nearly always diagnostic light is
afforded by definite tenderness and
morphological alteration in paraverte-
bral structures corresponding to the
origin of the sympathetic innervation
at the site of the subsidiary centers in
the spinal cord.
TREATMENT.— For internal use
salicylic acid and its compounds are
much employed and will sometimes,
though not in all cases, bring relief.
When the salicylates fail to effect a
cure, tincture of colchicum, potas-
sium iodide, or mercury may be. tried
together with an antigout diet.
Thiosinamine at times checks prog-
ress of chronic rheumatism. Daily
dosage of 0.06 to 0.1 Gm. (1 to 1^
grains) by injection or ingestion can
be safely employed. Renon (Bull, de
I'Acad. de Med., Apr. 25, 1911).
The following treatment of muscu-
lar rheumatism recommended: (1)
rest in bed; (2) liberal diet of milk,
eggs, light meats, farinaceous articles
and cruciferous vegetables. Butter-
milk and water between meals ad lib-
itum; (3) general bath daily, with
temperature progressively increased,
followed by a blanket or alcohol
sweat; (4) massage, after pain and
tenderness under control at least
twenty-four hours; (5) in lumbago or
other localized muscular troubles
where general methods inefficient:
acupuncture or injection directly into
involved muscle of 10 c.c. (2j/2 drams)
of ice-cold normal salt solution; (6)
where severe pain: salicylates, at
first in large hourly doses, with
sodium bicarbonate. Locally, 20 per
cent salicylic acid ointment or lini-
ment of oil of gaultheria, followed by
flannel jacket or bandages, with hot-
water bottles or electric pads. Meyer
(N. Y. Med. Jour., July 5, 1913).
Externally, tincture of iodine and
all the rubefacients — ammonia, cam-
phor, turpentine, etc. — are to be tried ;
also warmth in the form of hot water,
poultices, and hot baths (Russian or
Turkish). Hot-air baths have been
much recommended. The external
use of methyl salicylate often alle-
viates the pain. Belladonna plaster,
chloroform liniment, and the galvanic
current may also be used for this pur-
pose. Massage may completely cure
a recent case. Rest of the affected
muscles should be procured by all
means possible. In pleurodynia
strapping the side with adhesive
plaster generally affords marked re-
lief. In lumbago as well as in pleu-
rodynia light application of the
Paquelin cautery is frequently of
marked value. Otto has recom-
mended a single injection of 7^ to
15 grains (0.5 to 1 Gm.) of freshly
obtained sodium iodate in 5 per cent,
solution at the site of pain. Sajous
injects normal saline solution sub-
cutaneously — 2 fluidounces (60 c.c.)
■ — daily and gives, besides sodium
salicylate and sodium carbonate (not
bicarbonate) in full doses, watching
the heart carefully.
Injection of 5 or 10 c.c. (80 to 160
minims) of salt solution into the
muscle at the most painful point will
frequently relieve the pain, though, of
course, it has no effect upon the
cause. Schmidt (Med. Klinik, vi,
131, 1910).
The chief measure, other than rest
in bed, in the treatment of muscular
rheumatism is the application of heat
in the form of fomentations, poultices,
and hot-water bags. Dry cupping
over the tender region one-half hour
twice or thrice daily is very beneficial.
One or two electric-light bulbs placed
six inches from the affected part, a
piece of asbestos, tin or woolen ma-
terial encircling, so as to concentrate
24 RHEUMATISM (LEVISON AND SAJOUS).
the heat, will produce a useful hyper- den and severe strain on tendons and
emia; the skin should be protected by ligaments; (4) absorption of irritating
anointing with petrolatum. The elec- toxins from the alimentary tract; (5)
trie-light baking apparatus is, how- tonsillitis and pharyngitis; (6) influ-
ever, more serviceable. This treat- enza; (7) febricula. The forms most
ment the author has found verj' bene- commonly seen are: (1) muscular
ficial, together with light massage, rheumatism, involving especially the
after which a woolen cloth is placed muscles of the neck, those of the
over the hypercmic area. He has also shoulder and upper arm (brachial
found serviceable light massage with fil)rositis), the intercostal muscles, or
the use of an analgesic lubricant: — the lumbar muscles (lumbago); (2)
B MenthoVis Dupuytren's contraction; (3) fibrositis
Camphom.Az ?i-ij (4 to 8 Gm.). of the plantar fascia; (4) pads upon
Chlorali hx- finger-joints, usually confined to the
drati 3ss-j (2 to 4 Gm.). dorsal aspects of the proximal inter-
Olei gaultlie- phalangeal joints, and apparently un-
■yi^cc 5ii-iv (8 to 15 Gm.). related to rheumatoid arthritis, or
Adipis lance h\<- gout. In chronic villous synovitis,
drosi ...... Bi-ij (30 to 60 Gm.). though strictly not a form of fibro-
M, r, . sitis, the correct treatment is simi-
. et ft. unguentum. , ' , ^ ,
lar to that of the other conditions
After the patient is able to be out mentioned. It is purely local, usually
of bed a suitable adhesive plaster occurs in the knee, and characterized
dressing will allow him to walk, with ^^y crepitus or creaking on movement,
slight muscular fixation. J. H. Shaw ^^^ by p^j^ ^nd tenderness on use.
(N. Y. Med. Jour., July 5, 1913). j^ j^e treatment of an acute fibro-
When the disease has passed over sitis, a saline aperient should always
to the chronic sta-e further use of be given at the onset of the attack.
, - \ . . , r • 1 snd repeated as necessary. Saucy-
massage and electricity is beneficial. j^^^^ ^^^ ^^ jj^^j^ ^^^^^^.^^^ ^,^1^^^
Iodine ointment may be used with though aspirin is of decided use for
benefit. In cases attended by indura- the relief of pain in severe cases,
tion and fibrous nodules in the mus- Potassium iodide should always, if
cles, characterized often by contin- possible, be given in full doses of 10
, . ... or 12 grams (0.6 or 0.// Gm.), com-
uous and very intense pain, excision i • ^ vu ^ • i „„^ „«r^,v,
-^ . bined with tonics such as nux vomica
of the hard nodules of fibrous tissue or the compound glycerophosphate
often gives immediate relief. syrup. If symptoms of iodism result,
Chronic fibrositis is generally la- iodipin may be tried. Fibrolysin was
belled "rheumatic," but undoubtedly employed in several cases of thicken-
not a sequel of acute rheumatism, and "^S and contraction of fibrous tissues
in no sense connected with it; the es- i" different forms of fibrositis and
sential pathological change is, in arthritis, as well as in several cases
general, an inflammatory hyperplasia o^ Dupuytren's contraction, with good
of the white fibrous tissue in various results in about two-thirds ot the
parts of the body. Such aflfections cases. It should be injected under
cause pain and stiffness, the former strict antiseptic precautions into the
aggravated by any sudden movement. ^eep subcutaneous tissues of the
Recurrence is common and if not suit- "PP^^" a™' ^ach <.rm being injected
ably treated, the thickened fibrous alternately. It is necessary to give
tissue remains as indurations in 30 to 40 injections in all, and they
various' situations. The commonest should be administered on alternate
causes of local fibrositis are: (1) cold, days. After 20 injections have been
damp, and wet; (2) extremes of heat ' given movements and massage of the
and cold; (3) local injuries, as by sud- affected fibrous tissues should be
RHEUMATISM (LEVISON AND SAJOUS).
25
commenced. In the treatment of pads
upon the finger-joints the only pro-
cedure found useful besides fibroly-
sin was the nightly inunction of a 25
per cent, iothion ointment. In the
early stages of an acute fibrositis hot
fomentations are useful. Afterward
one of the best external applications
is a mixture of equal parts of chloral
hydrate, camphor, and menthol. The
resulting liquid should be painted over
the painful area, and then gently rub-
bed in with the fingers. Another use-
ful procedure is to paint the painful
area with tincture of iodine and then
apply a hot linseed poultice or very
hot fomentation. In the latter stages
the aconite, belladonna, and chloro-
form liniment applied on lint is fre-
quently most beneficial. In a very
localized fibrositis counterirritation,
especially by the thermocautery, is
sometimes of great use. Rest of the
affected parts and diaphoresis are two
of the most important procedures in
the treatment, the latter being es-
pecially beneficial at the onset of the
attack. Heat is of great value, and
if employed early will frequently
abort an attack. If it is to be applied
to the whole body the electric-light
cabinet is most convenient and val-
uable. In lumbago and chronic vil-
lous synovitis of the knees, the most
eflfective local treatment is super-
heated air, applied for fifteen or
twenty minutes, immediately followed
by ionization (cataphoresis) for ten
to fifteen minutes. In chronic joint
cases and chronic lumbago, the author
orders for ionization a 2 per cent,
solution of lithium iodide, directing
that the negative ion (the iodine)
should be driven into the tissues. In
acute lumbago a 2 per cent, solution
of sodium salicylate should be used
at the first sitting or two in order to
relieve the pain. In the later stages
of a muscular fibrositis a rapidly in-
terrupted faradic current is beneficial,
but it should be so weak as not
to cause any muscular contraction.
Massage is very useful in the later
stages, but it should not be employed
until it causes no pain, and should be
very gentle at first. During the pain-
ful stage of muscular rheumatism rest
of the affected muscles is required,
but later on exercises of the muscles
are of great benefit. They should be
performed on rising in the morning
and followed by a cold or tepid bath
and brisk rubbing of the skin with a
rough towel. No special dieting is
required; moderation should be the
keynote. Porous linen underwear is
the most suitable for rheumatic indi-
viduals. A. P. Lufif (Lancet, Mar. 12,
1910).
The distinguishing pathological fea-
tures of fibromyositis, according to J.
Madison Taylor, are plastic adhesions
of contiguous structures exerting
compression on sensory nerve-fibers
which need to be set free mechan-
ically. While this can be achieved by
various agencies such as by counter-
irritation, blisters, electricity, etc., the
most radical, prompt, and permanent
relief is by expert manipulation, such
as deep pressures with lateral traction,
torsion, etc. ; the best is by lifting and
separating the adherent structures,
thus freeing sensory fibers from com-
pression. In some cases, fibromyo-
sitis is so persistent as to remain for
many years a source of disablement,
lameness, or deformity, resisting all
medication, yet can be removed by
manipulation in a few days. Best re-
sults from medication by sodium ben-
zoate and Martin H. Fisher's alkaline
solution by colonic irrigation.
In any of the ordinary manifesta-
tions of chronic rheumatism, as lum-
bago, sciatica, pleurodynia, or cepha-
lalgia, and with any obscure myalgic"
or neuralgic pain in any part of the
body, a careful investigation should
be made of the fibromuscular tissues
of the affected areas. In the more
recent diffuse cases there is general
tenderness of these tissues. Usually,
either with or without such general
tenderness, one will find areas which.
26
RHEUMATISM (LEVISON AND SAJOUS).
are definitely, often exquisitely, ten-
der to touch. General treatment for
a feverish attack, with the ordinary
pain-relieving drugs, generally suffices
to cure. If the pain is at all localized
a single thorough application of mas-
sage may result in cure in this early
stage. y\ny discoverable cause, such
as gastrointestinal irregularities, must
be removed. During the more acute
exacerbat'ons sodium salicylate pi"o-
duces some relief, but recurrence is
probable indefinitely. To obtain a
permanent cure it is absolutely nec-
essary to obtain locally a complete
dispersal of the indurations. Coun-
terirritation by blistering or cau-
tery produces relief, but nothing is
so efficient as the rubbing in of oil
of gaultheria.. Important also are
massage and systematic exercises.
Acupuncture is of great use in reliev-
ing pain, but does not produce com-
plete dispersal of the infiltrations. In
cases of fibrous nodules w^hich will
not yield to simpler measures, and
which by pressing on nerves cause
persistent pain, excision is not only
advisable but necessary. Telling
(Lancet, Jan. 21, 1911).
Senile rheumatism described as a
separate morbid condition. Being
one of the manifestations of aging, it
can neither be prevented nor cured.
Pain can, however, be relieved. The
pain usually disappears soon after
joint motion has ceased, but if it per-
sists, application of moist heat, fol-
lowed by an inunction of 2 per cent.
cocaine liniment or ointment, using
an animal base, will generally give
relief. Sweet butter is an excellent
base for this purpose. To prevent its
becoming rancid 2 grains (0.12 Gm.)
of sodium benzoate to the ounce (30
Gm.) should be added. The constitu-
tional measures are hygienic and
medicinal, the latter consisting of the
intermittent use of phosphorus and
the iodide of arsenic. I. L. Nascher
(Amer. Med., Dec, 1911).
The writer emphasizes the value of
local heat, especially dry, radiant
heat, combined with ionization, in
muscular rheumatism. In lumbago.
the static current may be substituted
for ionization. Massage is useful, but
it should not be applied to the af?ccted
part itself, but around it. A. P. Luft
(Med. Rec, Aug. 16, 1913).
GONOCOCCAL (GONORRHEAL)
RHEUMATISM.
Gonococcal rheumatistn, or arthritis,
is an acute inflammation of one or
more articulations occurring during the
course of gonorrhea and caused by in-
vasion of gonococci in the joints.
SYMPTOMS.— The condition ordi-
narily appears in the acute stage of
gonorrhea. In some cases the lesion of
the joints is only revealed by arthralgia :
i.e., intense pain without swelling. This
condition is particularly observed in
the small joints of the foot. The pain
is worst in the evening and is aggra-
vated by movements. The arthralgia
may also precede the evolution of
gonorrheal arthritis or continue for
some time after the disappearance of
the swelling.
In other cases the affected joint be-
comes the seat of an effusion of fluid,
giving rise to little or no pain. This,
effusion disappears very slowly, and
often leaves stiffness or fibrous adhe-
sions in the joint. This form of the
disease is most frequently observed in
the knee.
Ordinarily gonococcal rheumatism in
its mode of invasion and evolution very
much resembles the acute form of ar-
ticular rheumatism. It differs from
that disease, however, in attacking only
one or a few articulations at the same
time, and in that the affected joints
remain involved for a longer period.
Again, gonococcal arthritis does not
migrate so suddenly from one joint to
another as the acute articular affection.
No joint, however, is immune, and
even those which ordinarily escape dur-
RHEUMATISM (LEVISON AND SAJOUS). 27
ing the course of rheumatic fever, e.g., gonococcal rheumatism is a rare occur-
the articulations of the jaws and the rence. It only happens when the infec-
neck, may be attacked by the gonococ- tion with gonococci is complicated with
cal arthritis. invasion of pyogenic organisms. The
The pain is of extreme intensity. It chronic form of gonococcal rheumatism
is aggravated by movements and by often gives rise to contracture of the
pressure over the swollen articulation, joints or periostitis of the epiphyses.
Many painful points are also found. DIAGNOSIS. — The diagnosis is
Tumefaction is ordinarily very marked ; easy when the urethral discharge is still
it is caused both by effusion into the present, but difficult when it is not.
joint and by edema of the overlying The disease may be confounded with
structures. The skin over the affected acute articular rheumatism and with
joint is hot and tense. osteomyelitis. In gonococcal arthritis,
Commonly the patient tries to allevi- but few articulations are attacked at
ate the pain by keeping the affected once. The mode of development of the
joint semiflexed. If he is allowed to arthritis, the extent to which the periar-
remain in this position, contraction of ticular tissues are involved, the rela-
the extremity may result. tive absence of constitutional symp-
Gonococcal rheumatism does not toms, the inefficacy of the salicylates,
affect the articulations alone. The and, if possible, the demonstration of
serous bursse and the sheaths of the gonococci in the blood or the affected
tendons in the proximity of the diseased joint constitute the chief distinguish-
joint are always involved ; sometimes ing features.
they alone suffer, the inflammatory ETIOLOGY. — Gonorrheal rheu-
process being thus periarticular — gono- matism is caused by an infection with
coccal tenosynovitis. The muscles of gonococci, and it is only observed as
the affected extremity are always af- the consequence of a gonococcal ure-
fected and generally become atrophied, thritis. Many authors have found the
In some cases one joint only is at- gonococci in material taken from the
tacked; the pain is, then, as a rule, still affected joints or synovial sheaths, and
more excruciating and the effusion some have even observed them, in the
greater than in the polyarticular form, blood. The disease attacks both sexes
The acute stage of the disease is not equally; it may occur in children as
usually of long duration. After some well as in adults. It develops in 2 per
days or a week the pain declines and cent, of all gonorrhea cases in the male
the effusion diminishes. The disease sex.
rarely disappears completely, however; PROGNOSIS. — The prognosis as
one or more joints remain somewhat to life is good, but very often the dis-
stiff and painful several months. The ease results in stift'ness of the affected
so-called painful heel of gonorrhea is joint and weakness of the limb, due
the result of a periosteal inflammation to atrophy of its muscles.
of the OS calcis, with or without exos- TREATMENT. — Treatment by
tosis. In some instances chronic gono- means of drugs given internally is
coccal arthritis assumes the form of a not of great value; the salicylates
persistent serous effusion. have little or no influence on the
Suppuration of the joints affected by course of the affection. The same
28
RHEUMATISM (LEVISON AND SAJOUS).
appears to be true of potassium
iodide, except in the chronic cases.
Ihe use of syrup of ferrous iodide in
doses of 10 to 60 minims (0.6 to 4 c.c.)
three times a day has been recom-
mended by J. C. Wilson. Oil of gaul-
theria in doses of from 5 to 20 drops
every two hours in milk has also
been recommended, \\niere acute or
chronic gonorrhea coexists, every
means should be taken to overcome
the urethral focus of infection. In
the more chronic cases the use of
tonics such as strychnine, arsenic,
and codliver oil may prove of value.
Gonococcus vaccines have given
excellent results in a certain propor-
tion of chronic cases. Antigonococcic
serum lias also been used.
At the onset of gonorrheal rheuma-
tism, the patient should receive a
purgative of calomel to be followed
by citrate of magnesia, or salts, or a
dose of castor oil. He should be put
on a light diet with plenty of liquids,
such as soup, milk, alkaline waters,
etc., avoiding stimulating articles of
diet as tea, coffee, spices, and alcohol.
The bowels should be kept regular
and the patient drink plenty of water.
H necessary, a mild diuretic can be
given. Codeine or morphine should
be given if necessary for the pain.
Phenyl salicylate, S grains (0.3 Gm.)
and antipyrin, 3 grains (0.2 Gm.)
may be given every three or four
hours for the fever. The oil of gaul-
theria in doses of 20 drops three
times a day, or potassium iodide,
has be:n recommended. Every case
should be treated at once with anti-
gonococcic serum or gonococcic vac-
cine. The combined bacterins seem
to be more useful than the single-
strain cultures. The initial dose is be-
tween 10 and 20 million, running the
same up every second, third, or fourth
day, until about 50 million are being
given every second or third day. Im-
provement is usually noticed within a
week or ten days, but the treatment
should be continued until all the
symptoms have su])sided, which may
take from four to six weeks. Broe-
man (Med. Rev., Sept., 1913).
Local treatment is of great impor-
tance. The affected joint should be
placed on a splint in a proper position
and alxsolute rest of the extremity
enjoined. Pain may be relieved by
various anodyne measures, e.g., hot
and cold applications, tlic ice-bag,
ointments of ichthyol or belladonna,
a wet dressing- of lead-water and
laudanum, or, if necessary, a hypo-
dermic injection of morphine. Coun-
terirritation may be instituted by
means of turpentine or iodine.
Gaucher procures relief for several
hours by bathing the part for half an
hour in a mixture of equal parts of
an aqueous emulsion of black soap
and of oil of turpentine; 5 to 6
fluidrams (20 to 25 c.c.) of this mix-
ture are used with 6 gallons (25
liters) of water. The genitals should
be anointed vvith petrolatum before
the bath is administered. Balzer
uses the following ointment: —
IJ Acidi salicyiici.
Old tcrebinthin<c,
Adipis lance hydrosi.aa Siiss (5 Gm.).
Adipis benzoinati 'Siij (100 Gm.).
Fiant unguentum.
In the intervals between local pro-
cedures a bandage should be applied
as firmly as is practicable. Or, a
plaster-of-Paris dressing may be
used for complete immobilization,
applied under anesthesia if necessary.
Straightening of the limb under anes-
thesia is necessary if fixation in a
faulty position has already taken
place.
In cases in which acute pain has
subsided massage and passive move-
ments are of value to assist in res-
RHUBARB.
29
toration of joint mobility. Dry hot-
air baths, Bier's passive hyperemia,
and counterirritation with bhsters or
the thermocautery are also very
serviceable measures in the more
chronic cases. The last two pro-
cedures are especially indicated in
cases characterized by hydrarthrosis.
Compression is also of value in these
cases.
Where the above fail to bring re-
lief within a reasonable period, and
especially if the effusion becomes
purulent, arthrotomy should be per-
formed and the joint evacuated and
irrigated with an antiseptic or sterile
saline fluid, according to indications.
Aspiration followed by injection of 1
to l^A fluidrams (4 to 6 c.c.) of a
1 : 4000 solution of mercury bichloride
has been recommended by P.alzer and
others, but the more radical pro-
cedure in general meets with greater
favor. Bres, in 20 cases, after incis-
ing the joint, removed the diseased
synovial membrane and injected
dilute tincture of iodine or a weak
solution of zinc chloride. All his
cases recovered completely.
F. Levison,
Copenhagen,
AND
L. T. DE M. Sajous,
Philadelphia.
RHEUMATOID ARTHRITIS.
See Joints, Surgical Diseases of,
RHIGOLENE. See Petroleum.
RHINITIS AND OTHER NA-
SAL DISORDERS. See Index.
RHUBARB. — Rhubarb, or rheum
(U. S. p.), is the root of Rheum officinale
and of other undetermined species of
Rheum (nat. ord., Polygonacc;c) : a plant
indigenous to Asia (China, India, Tar-
tary, and Thibet), but which is cultivated
in America and elsewhere. It contains
extractive, sugar, starch, pectin, lignin,
salts, several unimportant alkaloids, a
glucoside, and acids, one of which, chry-
sophanic acid, is used in medicine. In
commerce two sorts are recognized, —
the Chinese and the European, — the for-
mer of which is considered the better.
It occurs in irregular cylindrical or
conical, flattened pieces, which are gener-
ally perforated, are covered with a light
yellowish-brown powder, and have fre-
quently a wrinkled surface. Beneath the
powder the color of the root is reddish
brown, mottled with lighter hues. The
root is dense and hard and has a bitter
and somewhat astringent taste and a
peculiar aromatic odor. When chewed,
the root is gritty (due to the presence
of crystals of calcium oxalate), and im-
parts a yellow color to the saliva.
European rhubarb is inferior to the
Chinese variety; powdered rhubarb is also
inferior, and, if not adulterated, at least
is generally made up of inferior, dam-
aged, worthless or worm-eaten material.
PREPARATIONS AND DOSES.—
Rheum, U. S. P. (the root). Dose, 5 to
30 grains (0.3 to 2 Gm.).
Extractum rhei, U. S. P, (extract of
rhubarb). Dose, 5 to 15 grains (0.3 to
1 Gm.).
rUiidextractum rhei, U. S. P. (fluid-
extract of rhubarb). Dose, K to 1
dram (1 to 4 c.c).
Mistura rhei composita, N. F. (rhubarb
and soda mixture). Fluidextract of rhu-
barb, 15; fluidextract of ipecac, 3; bicar-
bonate of soda, 35; glycerin, 350; spirit
of peppermint, 35; water, sufficient to
make 1000 parts. Dose, 1 to 4 drams (4 to
16 c.c).
Pilulcc rhei compositce, U. S. P. (com-
pound rhubarb pills, containing rhubarb,
2 grains; aloes, V/2 grains; myrrh, 1
grain). Dose, 1 to 3 pills.
Pulz'is rhei coinpositus, U. S. P. (com-
pound rhubarb powder or Gregory's pow-
der, containing rhubarb, 25; magnesia,
65; ginger, 10 parts). Dose, ^ to 1
dram (2 to 4 Gm.).
Syrupus rhei, U. S. P. (syrup of rhu-
barb, containing fluidextract of rhubarb,
10 per cent.). Dose, 2 to 6 drams
(8 to 25 c.c).
30
RIGGS'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS).
Syni/^us rhei aromaticus, U. S. P. (aro-
matic syrup of rhubarb, containinjif
aromatic tincture of rhubarb, 15 per
cent.). Dose, 2 to 6 drams (8 to 25 c.c).
Tinctura rhci, U. S. P. (tincture of rhu-
barb— rhubarb 20 per cent.). Dose, Yz to
2 drams (2 to 8 c.c).
Tinctura rhci aromatica, U. S. P. (aro-
matic tincture of rhubarb — rhubarl) 20 per
cent.). Dose, K' to 3 drams (2 to 12 c.c).
POISONING BY RHUBARB.— Rhu-
barb is not generally considered poison-
ous, but a case has been reported in
which the internal administration of
rhubarb gave rise to a hemorrhagic
eruption of macules, pustules, and blebs.
The mucous membranes were also af-
fected, and free hemorrhage from the
urethra occurred.
THERAPEUTICS.— Rhubarb is an ex-
cellent stomachic tonic in atonic dyspep-
sia associated with deficient biliary and
intestinal secretion. It is a remedy espe-
cially adapted to those of relaxed habit,
but inadmissible when an hyperemia of
the mucous membrane exists.
Rhubarb is a valuable remedy in simple
constipation, where we wish to unload
the bowels without affecting the general
system. The root is often chewed by
adults to relieve constipation. In chil-
dren the syrup is a palatable preparation
for this purpose; the pill or compound
pill may be used by adults.
Constipation and hemorrhoids depend-
ing upon pregnancy are benefited by the
administration of rhubarb.
In the summer diarrhea of children,
with green stools, the aromatic syrup of
rhubarb may be employed to empty the
bowel of its fermenting contents before
giving direct treatment. The diarrhea of
indigestion in children and adults is re-
lieved by the aromatic syrup or by the
mixture of rhubarb and soda.
In children, when constipation is re-
placed by diarrhea, if any ordinary laxa-
tive is used, rhubarb is an available rem-
edy on account of its secondary astrin-
gent action.
Functional disturbance of the liver with
deficient biliary secretion is relieved by
the administration of rhubarb, either
alone or, better, combined with blue mass.
Rhubarb is an efficient remedy in duo-
denal catarrh and in catarrh of the biliary
ducts with jaundice, especially in chil-
dren. White, pasty, or clay-colored stools
and a skin of an earthy or jaundiced hue
are indications for rhubarb.
RHUS POISONING. See Der-
matitis Venenata.
RIBS, DISEASES AND INJU-
RIES OF. See Index.
RICKETS. See Bones, Diseases
OF.
RIGA'S DISEASE. See Mouth,
Lips, and Jaws, Diseases of.
RIGGS'S DISEASE; PYOR-
RHEA ALVEOLARIS (SPONGY
GUMS).— DEFINITION.— This is a
pyogenic inflammation of the gums,
apparently starting from the gum mar-
gins, and associated with a suppuration
of the peridental membrane of the
roots of the teeth, which tends to
loosen the latter by detaching them
from the surrounding alveolar tissue.
SYMPTOMS.— The earliest symp-
toms noted, as a rule, are sensitive-
ness, redness, and perhaps swelling of
the gums, with a tendency to bleed
when touched. The development of
the disease being insidious, these
signs are in reality those of an ad-
vanced morbid process, a fact shown
in many cases by the presence of
granular pustules around and under
the edges of the gums, due to the for-
mation of deep pockets between the
latter and the teeth. An offensive
breath and a coated tongue are usual,
and periodical attacks of toothache
also, though in some cases pressure
over the gums will always elicit a dull
pain ; occasionally the latter becomes
continuous. Loosening of the teeth
in their sockets occurs quite fre-
quently. A mild stomatitis is some-
times witnessed, and persistent glos-
RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS).
31
sitis with irregular exfoliation, leaving
red patches, may also occur.
The disease is obviously a chronic
one, but it may be attended with acute
exacerbations lasting from a few days
to several weeks, during which the
gums become very tender and bleed
spontaneously. During the ulcerative
process the submaxillary or cervical
glands may enlarge and become pain-
ful, suggesting tuberculosis.
Pyorrhea alveolaris is not infre-
quently the cause of systemic dis-
turbances.
Many cases of septic fever of un-
known origin and conditions diag-
nosed as malignant endocarditis, as
well as many deaths attributed to
acute septicemia, would have been
correctly diagnosed if the oral cavity
had been examined. Many deaths
due to alveolar abscess, tooth extrac-
tion, and septic oral conditions have
been reported.
C. H. Mayo interestingly stamps
pyorrhea as the cause, not the re-
sult, of systemic disturbances. Ap-
pendicitis being caused by septic oral
conditions has been confirmed by the
bacteriological investigations of Lanz
and Tavel.
Tooth extraction has given a com-
paratively high death rate. All cases
presenting pus should be afforded
free drainage until danger from in-
fection has passed. A. W. Fossier
(N. Y. Med. Jour., Aug. 7, 1915).
Many cases of alveolar abscess are
erroneously diagnosed as pyorrhea
alveolaris. This grave error was
much more common before the ad-
vent of rontgenology. It has been
found that the toxemia resulting
from a dental granuloma is far
greater than from a pyorrheal dis-
charge. M. L. Rhein (Surg., Gynec.
and Obstet., Jan., 1916).
DIAGNOSIS.— The differential
diagnosis is sometimes difficult to
establish from alveolar disease over-
lying necrosis due to poisoning by
lead, mercury, phosphorus, or other
elements used industrially. Syphilitic
or tuberculous lesions of the gums
may also cause confusion. Scurvy,
now rarely encountered, also causes
gingival lesions resembling closely
pyorrhea. In these various conditions
the history of the case and the course
of the disease are frequently of major
assistance in the differentiation from
true pyorrhea.
Unlike dental caries which is un-
common in "native" races, pyorrhea
alveolaris is probably as common in
them as in the civilized. It is very
common in domesticated animals,
while almost unknown in wild ani-
mals. The disease has increased
enormously in civilized countries dur-
ing the last few decades. Inefficient
mastication, whether due to pre-exist-
ing disease of the teeth or to the food
being too refined and soft, is a power-
ful etiological factor. Marginal gin-
givitis having been set up, infection
with organisms rapidly follows, and a
rarefying osteitis, commencing at the
inner margin of the sockets, soon sets
in. Lime salts from the pus become
deposited on the roots of the teeth,
at first around the necks just under
the gum margin, and later on the
deeper parts. This in itself acts as
an irritant, and so a vicious circle is
set up which must be broken before a
cure can be effected — the tartar causes
ulceration, which produces more pus,
which forms more tartar. Gibbs
(Edinb. Med. Jour., Oct., 1917).
ETIOLOGY.— Pyorrhea alveolaris
was for a time thought to be due to
the Endamcba gingiz'alis (Gros, 1849),
but later work seems to have definitely
shown that this organism cannot be
considered the causative agent. As a
matter of fact, there appear to be both
predisposing causes and exciting causes
which play a role in the production of
pyorrhea. Among the former are sys-
temic diseases, localized malnutrition.
2>2
RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS).
frail bony investment of the teeth, and
trauma resulting from malocclusion
(Merritt). As for the exciting cause,
it seems probable that anything causing
prolonged irritation of the gums may
act as such. Bacteriological studies on
the disease have been based largely on
cases in a frankly purulent state; it is
considered highly probable, however,
that a non-purulent inflammatory stage
of the condition, due to trauma and
constitutional influences, may occur be-
fore micro-organismal infection takes
place.
Such constitutional affections as
gout, diabetes mellitus, and other states
indicative of deficient or imperfecl
metabolism, while incriminated as pre-
disposing causes of pyorrhea, are by
no means essential in its production.
According to Maurice Roy, unduly
early senile absorption of the bony
tooth sockets constitutes the first stage
of pyorrhea. The most plainly evident
predisposing cause is age. After the
thirtieth year its development is ob-
served with growing frequency, until
about the fiftieth year. In persons who
take good care of their teeth through
cleanliness, expert attention to avoid
cavities, badly fitting crowns or fill-
ings, etc., pyorrhea tends to remain in
abeyance. Its harmful eftects are
likely to follow opposite conditions,
particularly uncleanliness and trau-
matisms of the gums by accumula-
tion of tartar, especially when de-
bilitating diseases, such as gout,
anemia, and infectious diseases, have
weakened the bacteriolytic activity of
the buccal secretions. Autointoxica-
tion of intestinal origin is also
thought to favor the development of
the disease, possibly by overtaxing
the defensive functions of the body,
thus favoring infection from any
source. It may likewise occur in tooth-
less gums when the false teeth are
not kept scrupulously clean.
There is a frroup of cases which
the writer suspects to be caused by
the spirochete of Vincent's angina.
He has seen several cases on record
where mothers have developed this
condition, and it has been followed
by an illness in tlie child, first diag-
nosed as diphtheria and then as Vin-
cent's angina. There are also cases
caused by the Treponema pallida. W.
Sterling Hewitt (Dental Cosmos,
Oct., 1915).
The teeth, as end-organs, are the
first to exhibit a diminution in im-
munity to infection, if any form of
malnutrition exists. If, by exercise,
massage, and other hygienic meas-
ures, circulation in the ultimate capil-
laries is kept moving, the gums and
peridental tissue will frequently re-
tain their immunity, even though
malnutrition be present. Pyorrhea
alveolaris is a result of malnutrition
plus infection, and also most fre-
quently plus irritation, and it is
greatly intensified if arteriosclerosis
of the ultimate capillaries sets in.
All forms must commence with some
form of gingivitis, but the tissues
vary markedly in clinical appearance.
The writer is inclined to recognize
particular types of pyorrhea accord-
ing to the associated disease, e.g., dia-
betic pyorrhea, tuberculous pyorrhea,
etc. The symptomatology and treat-
ment difTer in each type. The prog-
nosis largely depends on the possibil-
ity of curing the malnutritional fac-
tor. Often the pyorrheal changes
will appear long before the signs of
the underlying disease are sufficiently
developed to permit a diagnosis.
There are cases, however, in which a
decrease in the functional power of
the teeth themselves is the chief
cause. This is usually due to such
conditions as loss of one or more
teeth, irritation from unpolished fill-
ings, etc. Often when the underlying-
constitutional cause is found it will
not be recognized as such, but will
RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS). 33
be regarded as secondary to the pyor- may initiate pneumonia. The chronic
rhea. M. L. Rhein (Jour. Amer. processes of the series are benefited
Med. Assoc, Feb. 10, 1917)). ^^ autogenous vaccines in most in-
Hartzell's work points strongly to ^^^^^^^^^ j^ ^^^^^^ ^^^^^ ^^ ^,^^ ^.^^^^^
the importance of the streptococcus m .
pyorrhea, indicating that approxi- there IS apparently no pus. This seem-
mately three-fourths of the bacterial ing absence may be due to shallow or
content of the pus pockets is made up wide open pockets, the pus being
of pyogenic cocci of the Streptococcus cashed away by the oral secretions as
7'fru/fl;;.y and staphylococcus types, and ... ■. ■ r j •. u j
. ., r .1 rapidly as it IS lormed. or it may be due
the remammg one-tourth ot other . . -^
organisms. Personal observations to an inactive phagocytosis, or both
relative to the occurrence of strepto- (Merritt).
cocci, staphylococci, and pneumococci TREATMENT. — One important
in pyorrhea would place streptococci feature in this connection is the pres-
in the first rank as regards frequency, r i. j. i- i i .li i j
, , , . .1-1 ence of tartar, particularly the hard
staphylococci next, while pneumo- ^ •'
cocci are observed in only a small variety derived from blood-serum and
percentage of cases. A. W. Lescohier made up of various phosphates, car-
(Jour. Amer. Med. Assoc, Feb. 10, bonates and often dark in color. This
^^^'^- is a calculus which forms along the
PATHOLOGY. — The inflamma- edges of the gums and peridental
tory process starts at the margin of membrane. The first step is to care-
the gum and soon involves the dental fully rid the teeth of any tartar that
periosteum and surrounding alveolar may be present, and the gums of
wall. The latter being a medullary decayed teeth, badly fitting crowns
space in the maxilla, a morbid process and fillings, angular projections from
similar to osteomyelitis develops, end- the latter, etc. In a word, the patient
ing in necrosis. The endameba buccalis should be placed in the hands of a
can not infrequently be detected, and all competent dentist, who should be
the more common pyogenic bacteria informed of the end in view,
may occur in the lesions. The pneu- Introduction of an accessory medi-
mococcus is also found in most cases, cinal treatment of pyorrhea followed
As shown by Rosenow and Billings, the discovery of Barrett and that an
there is a close connection between actively motile Endameba buccalis
the pneumococcus and the streptococ- occurred in pyorrhea pus pockets,
cus, some strains of the latter taken The fact that dysentery, due to an
from tonsillar crypts having been con- endameba, yielded promptly to emetine
verted under various cultural con- hydrochloride suggested its use, a
ditions into typical pneumococci. solution of J^ per cent, of this salt
The same convertibility occurs in the being injected into the pockets. In
streptococci of pyorrhea. Hence the several instances of the 13 cases
fact that, precisely -as in the case with treated the pus disa]:)peared in 24
the tonsils, streptococci in pockets of hours and the gums assumed a health-
pyorrhea alveolaris may give rise to ier appearance after the third or sec-
rheumatic joint infections, arthritis ond injection. Bass and Johns (New
deformans, endocarditis, pericarditis, Orleans Med. and Surg. Journal, vol.
exophthalmic goiter, goiter, gastric Ixvii, p. 456, 1914) then tried the
ulcer, etc., while the pneumococcus drug hypodermically, giving y^ grain
8—3
34
RIGG'S DISEASE; PYORRHEA ALVEOLARIS (SAJOUS).
(0.03 Gm.) until the amebse had dis-
appeared and keeping up the effects
by local applications of 2 or 3 minims
(0.12 to 0.18 CO.) of the fluidextract
of ipecac to the gums with the tooth-
brush after carefully cleansing the
teeth. These agents sometimes seemed
curative in mild cases, but when the
morbid process was severe the organ-
ism was observed to recur.
Of 190 cases examined 187 showed
endamebffi. Of the 187, 78 have been
treated for pyorrhea. Of the 78
treated, none lost their endamebse
permanently. The condition of the
gums and teeth was greatly improved
in 3 cases, moderately improved in 9
cases, slightly improved in 22 cases,
while 41 cases remained the same;
the results were doubtful in 2 cases
and 1 case became worse. Practically
all that were found negative for
endamebjE at the conclusion of the
injections were found positive for
endamicbae from two weeks to four
months later, in spite of using a
solution of ipecac as a mouth-wash.
Emetine is an amebicide, but alone
will not cure pyorrhea alveolaris. J.
S. Ruofif (U. S. Public Health Report,
Reprint, 320, 1916).
Suspecting that pyorrhea is due to
certain spirochetes. Kritchevsky and
Seguin have used neoarsphenamine.
Good results in 60 cases reported
from mercury succinimide injections.
In the pyorrheal secretions numbers
of large spirochetes were observed
which generally disappeared almost
completely as a result of the injec-
tions. Among 244 cases the spiro-
chetes were found in large number in
three-fourths of all instances. In
healthy mouths, they were usually
absent or few. Six to 10 injections of
0.1 to 0.6 Gm. of neoarsphenamine
among 42 patients all showing numer-
ous spirochetes caused disappearance
of the latter in 29 cases, in the ab-
sence of all local treatment. Clinical
improvement was marked. The treat-
ment recommended for pyorrhea is as
follows: Intravenous injection of 0.1
to 0.3 Gm. of neoarsphenamine. If
contraindications or special technical
difficulties exist, intramuscular injec-
tions of mercury succinimide. Where
the tooth is entirely loosened and the
alveolar process destroyed, the tooth
had best be removed. If the process
is but partly involved the roots
should be scraped and even carefully
polished. Fluorine salts assist in
breaking up the tartar. Neoarsphena-
mine should also be introduced in the
pyorrheal pockets in solution or
powder form. Recurrence is obviated
only by persistent, careful cleansing
of the teeth. B. Kritchevsky and P.
Seguin (Presse med.. May 13, 1918).
Some observers have reported good
results from the use of a stock bacterin
or autogenous vaccine.
In the cases studied by the writers,
streptococci predominated, but were
associated in some instances, either
with Staphylococcus aureus, S. albus,
or with S. citreus. In 2 cases there
. was found an association of the strep-
tococcus and of the Bacillus pHeuinojiice,
once with the Micrococcus catarrhalis,
and twice with a pneumococcus.
A sensitized vaccine against the
streptococcus, staphylococcus, pneu-
mococcus, and bacillus of Friedlander
was thereupon prepared. For M.
catarrhalis a Wright vaccine was
made. Vaccine injections were then
made. After 2 injections, when the
antibodies began to take hold, a
mechanical and dental treatment —
Younger's — was begun. After from
4 to 5 injections, it was found impos-
sible, either by microscopic examina-
tion or by cultures, to discern the
presence of the bacteria. The authors
have kept in touch with a number of
cases for six months after treatment.
These cases have shown no recur-
rence. Bertrand and Valadier (N. Y.
Med. Jour., Jan. 10, 1914).
A stock vaccine may be used, either
sensitized or unsensitized, or an
autogenous vaccine prepared from
the pus pockets may be employed.
If the autogenous is preferred, care
ROCKY MOUNTAIN SPOTTED FEVER (WITHERSTINE),
35
should be taken to select an experi-
enced bacteriologist for its prepara-
tion. If an unsensitized bacterin is
employed, the initial dose advised is
ISO million of the mixed bacteria;
250 to 750 million may be given as
the initial dose if the sensitized cul-
tures are employed. Subsequent
doses are injected at intervals of
seven to ten days, gradually increas-
ing or decreasing according to indi-
cations. If the reactions are too
severe, the doses should be reduced
or temporarily discontinued. Every
dose should be carefully gauged by
the effect obtained from the preced
ing dose. If no improvement follows
the initial dose, subsequent injections
should be increased until amounts
large enough to produce a mild clin-
ical reaction (demonstrated by symp-
toms of malaise and possibly aggra-
vation of the local symptoms) are
reached. If a marked clinical reac-
tion occurs after a dose, characterized
by rising temperature, the next dose
should be smaller. F. E. Stewart (N.
Y. Med. Jour., Aug. 7, 1915).
Injections of succinimide of mer-
cury (1 grain — 0.065 Gm.) weekly are
announced as curative by Wright and
White (U. S. Navy), from one to six
doses having been sufficient in their
cases besides the local measures.
Copeland (Dental Cosmos, Feb.,
1916) confirms these observations.
He usd a B. W. 8z Co. glass syringe
holding 40 minims (2.5 c.c.) and a
No. 26 intramuscular needle, the
solution being % grain (0.013 Gm.)
of mercuric succinimide to 4 minims
(0.25 c.c.) of hot, sterile distilled
water. The injections are made into
the buttock after sterilization of the
skin.
The writer advocates surgical meas-
ures, removing the diseased tissues
under novocaine anesthesia, then pack-
ing with iodoform gauze to promote
drainage and granulation. The pa-
tient is shown how to flush his teeth
with warm saline solution after eat-
ing for the post-operative week. This
operation does not cure pyorrhea; it
is the only method which prevents
secondary infection. Nodine (Dental
Cosmos, Ixiii, 345, 1921).
The writer resorts to gingivoec-
tomy, cutting away under local anes-
thesia all loose, infected and diseased
tissues to eradicate peridental infec-
tion. He claims to have obtained a
cure in 90 per cent, of his cases.
Ziesel (Dental Cosmos, Ixiii, 352,
1921).
Time will probably show that such
active surgical procedures are un-
necessary to cure pyorrhea.
Prophylaxis is an important fea-
ture : scrupulous cleanliness of the
mouth and regular visits to the den-
tist to check any incipient disorder of
the teeth or gums.
C. E. DE M. Sajous,
Philadelphia.
RINGWORM. See Trichophy-
tosis.
ROCHELLE SALTS. See Po-
tassium AND Sodium Tartrate.
ROCKY MOUNTAIN SPOT-
TED FEVER (TICK FEVER).-
This eruptive disease has been known
in the valley of the Bitter Root River
in Western Montana and in Idaho
since 1873, although the first specific
reference to it in literature was made
in 1896 by the Surgeon General of the
Army in his annual report. The dis-
ease has since been reported from
nearly all the States in the Rocky
Mountain group, California, Colorado,
Idaho, Montana, Nevada, Oregon,
Utah, Washington and Wyoming.
Cases have also been reported from
the District of Alaska. The disease is
especially interesting on account of
its geographical limitation, seasonal
prevalence, intimate association with
36
ROCKY MOUNTAIN SPOTTED FEVER (WITHERSTINE).
wood ticks, and variation in severity
in different localities. It is api)arently
confined to the American Continent,
being- found only between 40° and 47°
north, and at an average elevation of
between 3000 and 4000 feet above
sea level. It prevails exclusively in
the spring and early summer; in the
Bitter Root cases the earliest was
March 17 and the latest July 17.
Those whose duties take them into
the brush and expose them to the bite
of ticks are subject to the disease,
especially stockmen, sheep herders,
miners, prospectors, lumbermen and
ranchmen. The greatest morbidity is
in persons between 15 and 50 years of
age, presumably because they are
most actively engaged in outdoor
work, and, for the same reason, males
most often fall victims to this disease.
It is not contagious ; 2 cases of the
disease have never been observed in
the same family the same season.
SYMPTOMS.— Incubation.— There
is a stage of incubation lasting from
three to ten days, usually about seven.
For a few days the patient complains
of chilly sensations, malaise, and nau-
sea, then has a distinct chill and takes
to his bed. Soon there are pains in
the back and head, and a feeling of
soreness in the muscles and bones,
with a sensation as if the limbs were
in a vice. The bowels are constipated
and the tongue is covered with a
heavy white coat, but red at the tip
and edges. The conjunctivae are con-
gested, and later become yellowish in
color. The urine is usually scanty
and contains albumin and casts.
Epistaxis, at times alarming, is
always present, and slight bronchitis
appears after a few days.
Fever. — Before the distinct chill
there is a slight rise of temperature
in the afternoon, l)ut little or no fever
in the morning. After the chill there
is an abrupt rise, with a gradual
increase of the fever in the evening,
and a slight morning remission, the
maximum being usually reached be-
tween the eighth and twelfth days.
In a favorable case it then gradually
falls, reaching normal about the four-
teenth to the eighteenth day, usually
going to subnormal for a few days.
In fatal cases the fever remains higli
(104° to 106° F.— 40° to 41.1° C.;,
and the morning remissions are either
absent or very slight. Yet the tem-
perature may rise to 105° or 106" F.
(40.6° to 41.1° C.) by the seventh or
eighth day, ending in favorable cases
by lysis on tlie ninth or tenth day.
Circulation. — The pulse is acceler-
ated out of all proportion to the
temperature, a pulse of 120 being
common with a temperature of only
102° F. (38.8° C.) ; the pulse usually
varies from 110 to 140; it is weak and
thready ; a full, strong pulse is excep-
tional ; during the first week it may
be dicrotic. There is a progressive
diminution in the number of red
blood-cells, but when the temperature
reaches normal an increase begins.
The white blood-corpuscles are
increased in number varying from
8,000 to 12,000; an average differen-
tial count would give : polymorphonu-
clear leucocytes, 77 .7 per cent. ; large
mononuclears, 11.4 per cent.; small
lymphocytes, 10 per cent. ; eosino-
philes, 0.9 per cent. ; the most marked
feature being an increase in the large
mononuclears. The hemoglobin is
steadily but slowly decreased — it may
go as low as 50 per cent. The blood
will not agglutinize Bacillus typhosus;
fresh and stained blood contains three
forms of the pathogenic parasite.
ROCKY MOUNTAIN SPOTTED FEVER (WITHERSTINE).
17
A sudden rise in the leucocyte
count is an unfavorable sign.
Eruption. — On the third day the
eruption usually appears, first on
the wrists and ankles, then on the
arms, legs, forehead, back, chest, and,
last and least, on the abdomen.
Although the other portions of the
body may be closely covered by the
eruption, it is always scanty on the
abdomen.
The spots are at first bright-red,
always macular, and in size from a
pinpoint to a split pea, at first dis-
appear on pressure and return quickly ;
in severe cases they rapidly become
darker, even purplish in color. From
the sixth to the tenth days of the
disease, the spots do not disappear on
pressure and are decidedly petechial
in character. In favorable cases,
about the fourteenth day they lose
their petechial character and disap-
pear slowly on pressure. The erup-
tion may assume the appearance of a
turkey-egg, the skin being flecked
with small, brownish spots. The erup-
tion fades as the fever declines, but
an access of fever, a warm bath, or a
free perspiration will bring it out dis-
tinctly. Desquamation begins when
convalescence is well advanced and
is general. In very severe cases there
may be gangrene of the fingers, toes,
and more frequently of the skin of the
scrotum and penis. Jaundice is
always present, first in the conjunc-
tivae and later involving the entire
cutaneous surface.
The Gastrointestinal Tract. — The
tongue is covered at first with a
heavy, whitish coat, except on the
edges and tip, which are red ; later the
coating is dark brown and sordes
covers the teeth. The appetite is often
good throughout the first week.
although there may be slight nausea.
In fatal cases the nausea increases
during the second week and persists.
Constipation is always present and
continuous. Gurgling is seldom found
m the right iliac fossa and tympanites
is never excessive. Moderate increase
in the size of the liver is present, and
the spleen is enlarged early and may
extend one or two inches below the
ribs. Black vomit is common.
The Urinary Tract. — The urinary
output is one-half the normal. Albu-
min in small amount is present in all
cases, associated with granular, hya-
line, and epithelial casts. Nephritis
may appear early in the history of
the case.
The Respiratory Tract. — The res-
pirations are always accelerated, be-
ing usually from 26 to 40 per minute,
although they may reach 50 to 60;
they are regular but often shallow.
Slight bronchitis always appears in
the second week. In fatal cases lobar
pneumonia is a frequent complication.
Epistaxis is generally observed from
the beginning of the second week.
Nervous System. — Headache and
pains in the back are usually severe
during the first week. A feeling of
soreness in the muscles and bones,
often very severe, even in mild
cases, is present and persists until
recovery. The mind is usually clear,
in severe cases, until a few hours
before death.
DIAGNOSIS. — Diagnosis Is usually
easy in cases occurring in infected
localities, which present a history of
tick-bites and the typical symptoms of
this disease; a blood examination will
clear up any doubtful case. There
are, however, five diseases to which
it bears more or less close resem-
blance from which this disease must
38
ROCKY MOUNTAIN SPOTTED FEVEK (VVITHERSTINE).
be differentiated: deni^ue, cerebro-
spinal menins^itis, pcliosis rhcumatica,
typhoid and ty])hus fevers.
Dengue is a disease of tropical and
subtropical countries, while spotted
fever is found at elevations of from
3000 to 4000 feet above sea-level
The swollen joints, polymorphic erup-
tion (never petechial) over the joints,
apyretic period, and short duration of
dengue would distinguish it.
Cerebrospinal meninyitis is marked
by the characteristic stiffness of the
neck muscles, photophobia, extreme
sensitiveness to sudden noises, head-
ache, rigidity of the muscles of the
back and neck, and a rash which is
not only irregular in location, but also
in appearance.
Peliosis rhemnatica is a compara-
tively rare disease in which there is
a characteristic sore throat associated
with multiple arthritis, purpura, and
urticaria.
Typhoid fever clinically closely
resembles spotted fever except in the
rose-colored spots (papular) which
appear first on the abdomen, the diar-
rhea, the Widal reaction, the presence
of typhoid bacilli in blood-cultures,
and the absence of the parasites
formed in the red blood-cells of spot-
ted fever.
Typhus fever so closely resembles
spotted fever that cases of typhus
fever occurring in a spotted-fever dis-
trict, without a blood examination and
close clinical observation, might easily
be counfounded with it. In typhus
fever, however, we have a larger incu-
bation, absence of tick-bites, the erup-
tion which appears first on the abdo-
men and chest, and an intensely con-
tagious character. Typhus is, more-
over, especially prevalent during the
winter months, and not during the
late spring and early summer, and is
accompanied by marked nervous
sym])toms.
ETIOLOGY.— Spotted fever is
caused by a protozoan parasite which
is transmitted to man thrrjugh the
bite of the wood tick (Dermacentor
andersoni). To Wilson and Chowning
belongs the credit of discovering this
parasite, three forms of which have
been identified by John F. Anderson,
the most common is a single ovoid
body, refractile, situated within the
red blood-cell, usually near its edge,
and closely resembling the earliest
intracorpuscular parasites of estivo-
autumnal malaria. When the blood
upon the freshly prepared slide is
warmed the parasite quite rapidly
projects pseudopodia and may change
its position slightly. A second form,
somewhat rarer, is larger, and larger
at one end and showing there a dark,
granular spot; this form is also ame-
boid. The third form, arranged in
pairs, is pyriform in shape, with the
smaller end approaching, and in some
cases being united by a fine thread.
The parasite is developed in the
female tick and the young ticks, after
being hatched, transmit the infection.
The female gets her infection by bit-
ing one convalescent from spotted
fever.
Three types of the spotted fever
parasite can be recognized: (1) An
extranuclear bacilius-Hke form with-
out chromatoid granules, relatively
large and only present in ticks dur-
ing the initial multiplication of the
parasites; (2) a relatively small rod-
shaped form with chromatoid gran-
ules, probably the same form seen
within nuclei in sections of ticks, and
rarely in smooth muscle cells in the
blood-vessel of mammals; and (3) a
relatively large lanceolate paired form
present in ticks and in the blood and
RUBELLA (CRANDALL).
39
lesions in mammals. The name Der-
macentroxcmis rickcttsi is proposed.
S. B. Wolbach (Jour. Med. Re-
search, Nov., 1919).
PROGNOSIS. — The mortality
varies between 70 and 90 per cent.
Death usually occurs between the
sixth and the twelfth day. There is
no relation between abundance of the
eruption and severity of the disease.
TREATMENT. — Quinine bimuri-
ate in 15-grain (1 Gm.) doses every
six hours, preferably hypodermically,
has yielded excellent results in the
hands of Wilson and Anderson. Qui-
nine sulphate, 15 grains (1 Gm.), may
be given by mouth every four hours,
and should be begun as soon as the
■diagnosis is made, and persisted with
in decreasing doses as convalescence
begins. The heart should be sup-
ported with strychnine, whisky (egg-
nog), or other cardiac stimulants.
The severe pain in the head and
back, during the first week, may be
relieved by the use of Dover's powder
or morphine sulphate. It is well to
flush the kidneys through the use of
copious draughts of water. Warm
sponge baths or packs are useful in
controlling the fever. The room
should be darkened and free from
noise. In the way of diet milk, butter-
milk, broths, soft-boiled eggs, and
moistened toast may be given.
In the way of prophylaxis, Ander-
son advises that as soon as a person
is bitten by a tick the insect should
be removed and 95 per cent, carbolic
acid applied to the spot. If there is
difficulty in removing the tick, Ander-
son suggests the application of
ammonia, turpentine, kerosene, or car-
bolized petroleum to it.
The treatment is rather unsatisfac-
tory, being mainly supportive and
symptomatic; the only drug of much
service is sodium citrate given in-
travenously to the limit of tolerance
from the start. Sixty c.c. of a 5 per
cent, fresh sterile solution may be
given intravenously twice daily. H.
C. Michie and H. H. Parsons (Med.
Rec, Feb. 12, 1916).
C. Sumner Witherstine,
Philadelphia.
RUBELLA, Rotheln, German
measles.
DEFINITION. — Rubella is an
acute, infectious, contagious disease
of mild character, presenting some-
what variable symptoms and running
a favorable course. Its identity as a
disease, siii generis, was long doubted.
There is now no question, however,
that it is a distinct entity among dis-
eases, though it strongly resembles
in its different manifestations measles
and scarlet fever. No better state-
ment of present beliefs regarding its
true character has been made than
that of Griffith, which is as follows :
"(1) rubella is a contagious, eruptive
fever, and not a simple affection of
the skin; (2) it prevails independently
either of measles or of scarlet fever;
(3) its incubation, eruption, invasion,
and symptoms diff'er materially from
both of these diseases ; (4) it attacks
indiscriminately and with equal sever-
ity those who have had measles and
scarlet fever and those who have not,
nor does it protect in any degree
against either of them; (5) it never
produces anything but rubella in
those exposed to its contagion ; (6) it
occurs l)Ut once in the indi\'idual."
PERIOD OF INCUBATION.—
This period is, according to Holt, 8
to 16 days, the limits being 5 to 22
days ; Rotch, 21 days ; Edwards, 7 to
14 days ; Plant, 1 to 3 weeks ; Smith,
about 2 weeks. These figures clearly
40
RUBELLA (CRANDyVLL).
show that the period of incubation is
of considerable length and extremely
variable. The indefiniteness arises
not so much from lack of observation
as from variability in the disease. To
say that the period of incubation is
about two weeks is probably as cor-
rect and definite a statement as can
be made.
SYMPTOMS.— The symptoms of
rubella are extremely variable, so
much so in fact that we must agree
with Rotch that it is impossible to de-
scribe a typical case in such a way
that the disease can be certainly di-
agnosticated in a sporadic case.
Many cases, however, run a fairly
consistent and characteristic course.
The invasion is seldom severe. In
some cases there is a prodromal stage
lasting a few hours ; in others the
rash is the first svmptom to be ob-
served. The fever is rarely high and
often does not rise above 100° F.
(37.8° C), but commonly, when at its
height, on the first day of the erup-
tion, it reaches 101° or 102° F. (38.3°
or 38.9° C). It occasionally rises to
104° F. (40° C.) or more. The
drowsiness, stupor, and other evi-
dences of serious illness so frequently
seen at the height of measles are
rarely, if ever, seen in rubella. A
child with a bright and very exten-
sive eruption will frequently show no
sign of general illness.
In my own experience sore throat
has been the rule. The tonsils and
pharynx are red and swelled and there
is pain on swallowing. This is oc-
casionally so marked as to be sug-
gestive of scarlet fever; the vomiting
so common at the outset of that dis-
ease, however, is rarely present. A
secondary sore throat which comes on
as the disease is subsiding was first
noted by Eustace Smith as very char-
acteristic of rubella. It certainly oc-
curs in some cases. Koplik's spots
do not ai)pear. The symptoms of the
]M-imary angina subside on the second
or third day and rapidly disappear.
There are no catarrhal symptoms in
most cases, but occasionally slight
suffusion of the eyes and a mild ca-
tarrh will render the diagnosis from
measles more difficult. Albuminuria
is rarely if ever present, and the diazo-
reaction is extremely rare. Moderate
leucocytosis occurs during the incu-
bation period, but disappears as the
eruption fades.
Hematological diagnosis of ro-
theln. Three cases under treatment
appeared clinically as measles, but
the first soon proved itself rotheln.
Two weeks later two similar cases
were admitted. The writer then com-
pared the blood-counts of the cases
with examples of true measles. He
found that in rotheln at the high
point of the disease there was none
of the disappearance of eosinophiles
which characterizes measles; nor was
there the leucopenia regarded as
normal in the latter disease. Schwaer
(Mitnch med. Woch., May 27, 1913).
Enlargement of the postcervical
and suboccipital glands is a very con-
stant and very characteristic symp-
tom of rubella. Numerous small
glands may almost invariably be felt
behind the sternomastoid well down
toward the shoulder; they rarely be-
come very large and never suppurate.
They may be felt most distinctly
when the rash is at its height, and
disappear rapidly. While they aid
materially in diagnosis, and may per-
haps be called diagnostic, they are
certainly not pathognomonic, for they
may at times be met in measles and
in rare cases be found in scrofulous
children without febrile symptoms.
RUBELLA (CRANDALL).
41
Most salient features by which one may distinguish rubella from measles
and scarlet fever are as follows, as given by N. S. Manning: —
Rubella.
Measles.
Scarlet Fever.
Invasion
Nil.
Three to five days,
with pyrexia and
conjunctival and
bronchial catarrh.
Twelve to twenty-
four hours, pyrexia,
headache, and
vomiting.
Catarrh
Slight or absent.
Marked conjunctivitis,
coryza, cough, etc.
Absent.
Eruption
Appears on face and
chest as bright,
pink-red maculre,
first under the cuti-
cle, which become
raised, with tend-
ency to spread and
Appears on face as
darkish-red, slight-
ly raised papules ;
extends to trunk
and limbs ; papules
become confluent,
but distribution is
Appears on chest as
diffuse general red-
ness of skin.
form irregular
patches or become
diffuse.
more uniform.
Throat-lesions
Slight swelling and
injection of fauces.
Fauces injected.
All the faucial struct-
ures acutely in-
flamed, swelled and
red, or ulcerated.
Tongue
Furred.
Furred.
Thickly furred, which
begins to strip off
in twenty- four or
forty-eight hours.
Superficial lymphatic
glands
Always enlarged in
axillt-e, groins, and
behind stcrnomas-
toid muscle in neck.
May be enlarged at
angles of jaw and
behind sternomas-
toid muscle.
leaving raw sur-
face, with enlarged
papill?e.
May be enlarged at
angles of jaw and
behind sternomas-
toid muscle.
Desquamation
Absent or very slight.
Branny.
Characteristic peeling
off of large pieces
of epithelium.
Forchheimer describes an exan-
them which is seen in the mouth as
the exanthem appears on the body. It
usually lasts about twenty-four hours.
"It consists of a macular, distinctly
rose-red eruption, upon the velum of
the palate and the uvula, extending
to but not on the hard palate. The
spots are arranged irregularly, not
crescentically, of the size of large
pinheads, very little elevated above
the level of the mucous membrane,
and do not seem to produce any reac-
tion tipon it."
The eruption appears first upon tlie
face or forehead and extends rapidly
over the neck, trunk, and limbs. The
whole body is usually covered within
twenty-four hours. Occasionally the
child will wake in the morning with
a rash covering the greater portion of
the body. In many cases the rash is
limited to small areas, the greater
portion of the body escaping entirely.
It is more constant upon the face than
any other region. In some cases the
rash continues not more than twenty-
four hours, but, as a rule, it is present
from two to four days. Itching is
common at the outset.
42
RUBELLA (CRANDALL).
A slight, scaly desquamation may
follow the disappearance of the rash,
but in many cases no desquamation
can be detected. This is particularly
true when inunction of the body has
been practised.
The eruption consists of papules or
maculopapules of a red or rose-red
color. They vary greatly in size,
varying from a pin's-head point to a
large blotch. Tliis multiform charac-
ter is one of the peculiarities of the
eruption of rubella. IMost of the
spots are smaller than those of
measles and larger than those of scar-
let fever. They vary in size on differ-
ent portions of the body, and even in
the same region the rash will be
found, as a rule, to be made up of
small dots interspersed with larger
and irregular-shaped spots or blotches.
It lacks the uniformity of the rash
seen in scarlet fever or measles. The
rash more commonly resembles that
of measles and it is frequently impos-
sible to make a diagnosis from it
alone. Edwards has recently alleged
that he has not seen the rash resem-
ble that of scarlet fever. That is not
my experience. I have frequently
seen a rash consisting of small points
grouped closely upon a reddened
skin that looked extremely like scarlet
fever. Search over the body, in such
cases, however, will usually reveal
small areas of eruption composed of
maculopapules, appearing as large
spots. These are commonly found
upon the arms, wrists, or hands. I
quite agree with those who describe
a scarlatinal and rubeolar type of
eruption. I have seen these two types
well marked in two children of the
same family exposed at the same time,
and ill in the same room. The rash
of one, consisting of large maculo-
papules ver}' strongly resembled
measles; that of the other, consisting
of much finer points on a reddened
skin, as strongly resembled scarlet
fever.
A disease was described by Clem-
ent Dukes, of England, in 1900, to
which he gave the name of "Fourth
Disease." The condition which is de-
scribed is virtually that which I have
here described as the scarlatinal form
of German measles. The differential
diagnosis given by Dukes between
German measles and fourth disease
describes a condition identical except
as to the rash. He admits that in
the same patient the eruption some-
times resembles measles and may
change later to a scarlatinal type.
The subject has received extended
study since Dukes promulgated the
theory of a fourth disease. After care-
ful observation of 1335 cases seen in
the London Fever Hospital, Beards
and Goldie did not see any they felt
thev could record as fourth disease.
AVatson Williams made a very care-
ful study of 2)2 cases of rubella and
questions the existence of a fourth
disease. Pleasants, of Baltimore, also
concludes that the existence of a new
exanthematic disease has not been es-
tablished. After an extended review
of the whole subject Ker concludes
that the fourth disease is either mild
scarlet fever or atypical rubella.
From study of the literature and from
considerable experience it seems to me
that we have not sufficient evidence
to warrant us in describing a fourth
disease.
ETIOLOGY.— Analogy leads to
the belief that rubella is caused by a
specific micro-organism, but the germ
has not yet been discovered. It is
contagious, though not as strongly so
RUE.
43
as scarlet fever and measles. Its con-
tagious power at times seems to be
very slight. It is most contagious
when the eruption is at its height. It
is rarely, if ever, seen under six
months, but after that age no period
of life is exempt. It is most common
between 5 and 10 years. The recur-
rence of true rubella is rare. The
disease usually occurs in epidemics,
which are most common in the spring.
COMPLICATIONS AND SE-
QUELJE. — No other infectious dis-
ease is so free from complications.
This is, in fact, one of the most
marked peculiarities of rubella. Even
varicella sometimes shows a serious
complication : that of gangrene. No
such serious symptom is likely to arise
in rubella. The pneumonia, otitis,
erysipelas, and multiple abscesses,
which in rare instances have been re-
ported as accompanying rubella, are
perhaps not in every case a complica-
tion, but rather a coincidence.
The writer reports the following
unusual case: The patient, a male, de-
veloped, after a few days of sore
throat, stifi neck, malaise, and moder-
ate fever, a rash having the distribu-
tion and appearance of German meas-
les and accompanied by an enlarge-
ment of superficial glands, notably
those of the neck. Before the exan-
them had faded the patient began to
complain of stiffness and tenderness
in the knees and ankles, and soon
all the interphalangeal joints of the
fingers presented the spindle-like
swelling commonly seen in rheuma-
toid arthritis. There was no exacer-
bation of temperature and neither
cardiac nor other complication. A
fortnight from the appearance of the
rash all the symptoms were subsiding,
and in the six months there was only
an occasional transient stififness in
the fingers. D. A. Alexander (Lan-
cet, ii, p. 921, 1907).
In an epidemic in an institution
for children, out of 80 cases 2
children developed chickenpox before
recovering from rubella, 1 developed
rubella before recovering from chic-
kenpox, and 1 child had a severe
ulcerative stomatitis. May Michael
(Arch, of Pediat., Aug., 1908).
PROGNOSIS. — Death from ru-
bella is extremely infrequent. In rare
cases in which it occurs it is usually
the result of some pulmonary disease,
occurring either as a complication or
as a coincidence.
TREATMENT.— Rubella requires
very little, if any, treatment. Mild
treatment appropriate to any febrile
condition is permissible, but if the
patient is kept in bed while the fever
and rash continue, and is anointed
daily with oil, further treatment will
rarely be required. Symptoms must
be treated as they arise. In most
cases the disease as such is of but lit-
tle importance, its chief interest lying
in its diagnosis, owing to its resem-
blance to two more serious diseases.
Floyd M. Crandall,
New York.
RUBEOLA. See Measles.
RUE.— Rue (Ruta) is the leaves of
Riita gravcolens (fam. Rutaceas), a peren-
nial herb or undershrub of Southern Eu-
rope, but cultivated elsewhere as a domes-
tic medicinal herb. The important con-
stituent (0.06 per cent.) of rue is a volatile
oil, colorless or slightly yellow and of low
specific gravity, and extremely unpleasant
and odorous. It was official in the U. S.
r. from 1870 to 1890. Rue also contains
a glucoside (rutin-rutic or rutinic acid)
which is yellow and crystalline and ap-
parently identical with the barosmin of
buchu, considerable sugar, and possibly a
volatile alkaloid.
PREPARATIONS AND DOSES.—
Oleum mice (oil of rue). Dose, 3 to 6
minims (0.20 to 0.40 c.c), in capsule.
Ruta (rue). Dose, 15 to 30 grains (1 to
44
SACCHARIN.
2 Gm.), usually in infusion. Neither
preparation is now official.
PHYSIOLOGICAL ACTION.— Rue is
a local irritant and vesicant. Internally
it is a stimulant, carminative and em-
menagogue. In large doses it is an
irritant poison, producing severe gastro-
enteritis, vomiting, abdominal pain and
meteorism, bloody stools, suppression of
urine, or stranguary, and epileptiform con-
vulsions. Dimness of vision with con-
tracted pupils are observed. Abortion may
result from toxic doses. It has some spe-
cial action upon the genitourinary tract,
and is eliminated in the breath, the urine,
and in the perspiration. It is rarely fatal,
THERAPEUTIC USES.— In medicinal
doses it is given as a uterine stimulant in
atonic amenorrhea, menorrhagia, and me-
trorrhagia. Its employment as an aborti-
facieiit entails great danger to the mother.
Hysteria, especially when associated with
amenorrhea, is benefited by the drug. It
has also been friund xiscful in flatulence
and infantile convulsions. In defective
activity of the sexual organs, it acts as
an aphrodisiac and emmenagogue. The
bruised leaves of rue laid upon the fore-
head has been used by Phillips to check
epistaxis. Added to liniments rue has
found favor as an application to the
chest in chronic bronchitis. A decoction
of the fresh leaves may be used as
an injection against seatvirorms (oxyuris)
and has often been given internally to
expel roundworms (ascarides). W.
SACCHARIN. —Saccharin (benzo-
sulphiiiidum, U. S. P.; glusidum, Br.;
neosaccharin; gluside; benzoyl sulphonic-
imide), or the anhydride of orthosulpha-
mide- — benzoic acid (C7H5NO3S), is a coal-
tar derivative obtained commercially from
toluene discovered by C. Fahlberg in 1879.
Saccharin occurs as a white, crystalline
powder, nearly odorless, having an in-
tensely sweet taste even in dilute solu-
tions. Iti is soluble in 250 parts of water
and in 25 parts of alcohol, and but slightly
soluble in ether and chloroform. It read-
ily dissolves in 24 parts of boiling water.
Saccharin dissolves also in glycerin. Its
solubility in water is promoted by the ad-
dition of sodium bicarbonate in the pro-
portion of 2 parts to 3 of saccharin.
Saccharin forms soluble salts with the hy-
drates of the alkaline metals. It melts at
220° C. (428° F.), and when fused with
potassium or sodium hydroxide it forms
salicylic acid. It is 300 times sweeter than
cane-sugar.
Sodium saccharin, also known as soluble
saccharin, soluble gluside, and crystallose,
is prepared by neutralizing an aqueous
solution of saccharin with sodium car-
bonate or bicarbonate and slowly crys-
tallizing the solution. It occurs in color-
less crystals, very soluble in water, in-
tensely sweet to the taste, and not dis-
colored by concentrated sulphuric acid.
It is a favorite substitute for saccharin be-
cause of its greater solubility.
Saccharin when present in food products
or mixtures may be separated by extract-
ing the saccharin from an acidulated
solution of the substance with ether, sep-
arating the ether and then evaporating the
ethereal solution thus obtained. The aver-
age dose of saccharin is 3 grains (0.2 Gm.).
PHYSIOLOGICAL EFFECTS. — Sac-
charin apparently is not decomposed in
the body, as it is excreted by the kidneys
imchanged; the urine, however, does not
so readily undergo fermentation and the
chlorides are increased. Mathews and
McGuigan, in studying the effects of sac-
charin on oxidation and digestion, report
that it has a marked retarding action on
oxidation in the blood and muscles, and
also on the action of the digestive juices,
especially those of the salivary glands
and pancreas. Its prolonged use is likely
to cause digestive disorders. When in-
jected into the circulation of an animal, it
produces depression and stupor, followed
by labored respiration, similar to asphyxia.
The writers attribute these effects to its
inhibitory action on the enzymes of the
blood and tissues, which also explains the
headaches and other symptoms its use
often gives rise to. It is believed to be a
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 45
general protoplasmic poison in that it in-
hibits fiearly all the fermentative processes
of the body, and interferes with and
diminishes general bodily metabolism.
Saccharin has antiseptic properties which,
however, are impaired in the presence of
an acid medium.
POISONING BY SACCHARIN.—
Large doses of saccharin are capable of
producing marked toxic symptoms, as in
a case reported by Luth, where a woman
having swallowed about 30 grains (2 Gm.)
of saccharin was found in a state resem-
bling that of alcoholic intoxication. She
was unconscious and foamed at the mouth.
Her face was flushed and she suffered
from convulsive attacks, with choking.
The respirations were rapid and the pulse
weak, very rapid, intermittent, and irregu-
lar. Poisoning by saccharin is rather rare.
TREATMENT OF POISONING.— In
the foregoing, under artificial respiration
and massage of the heart, the pulse within
half an hour became stronger and regular,
and the respiration became normal. After
forty-five minutes the patient awoke and
felt quite well.
THERAPEUTIC USES. — Saccharin is
chiefly used as a sul)stitute for sugar in the
diet of obese and diabetic patients. Tablets
containing Yi grain (0.03 Gm.) of saccharin
combined with a small quantity of sodium
bicarbonate are conveniently carried by
these patients to be used in tea, coffee, etc.
It may also be prescribed in the form of
a syrup containing 10 parts of saccharin
and 12 parts of sodium bicarbonate in 1000
parts of distilled water, made with gentle
heat at 104° F. (40° C). Saccharin in small
doses has been used in acid dyspepsia and
in chronic cystitis with ammoniacal urine.
Two parts of saccharin in solution with
3 parts of sodium bicarbonatei forms a
good tooth-wash. Aphthae yields to sac-
charin; 15 grains (1 Gm.) of saccharin are
dissolved in IJ/2 ounces (50 c.c.) of alcohol,
of which a teaspoonful is added to a half-
cup of water, and used to wash the mouth
thoroughly four or five times a day. It
may be used to cover the taste of quinine,
1 part of saccharin to 2 of quinine be-
ing used. As saccharin retards the action
of all the digestive ferments, it is contra-
indicated in cases in which digestion is
already impaired. W.
SALICYLIC ACID, THE SAL-
ICYLATES, AND SALICIN.—
Salicylic acid, chemically ortho-oxy-
benzoic acid [C6H4(OH)COOH] is
an organic acid existing naturally in
the oils of wintergreen (GaiUthcria
procumbcns) and of sweet birch
(Bctula Icnta) in combination as
methyl salicylate. It was first arti-
ficially made in 1874 by Kolbe, who
produced it from phenol, cailstic soda,
and carbon dioxide with the aid of
moderate heat and subsequent treat-
ment with hydrochloric acid. The
solubility of salicylic acid in water,
normally relatively slight, is increased
by the addition of the phosphates,
citrates, or acetates of the alkalies,
and by borax (sodium biborate).
Pure salicylic acid should be free from
color and from the odor of phenol ;
when heated on platinum foil, it
should leave no ash.
Various salts of salicylic acid are
official. There are also in common
use a number of other substances con-
taining the salicyl radicle, including
such drugs as acetyl-salicylic acid and
salicin. The last named, a glucoside
obtained from the bark of several
species of Salix and Populiis, supplied
the original name for the entire group
of drugs, the word salicyl being
derived from Salix.
PREPARATIONS AND DOSE.
— the following salicyl preparations
are official : —
Acidum salicylicnm, U. S. P. (sali-
cylic acid), occurring in fine prismatic
needles or a bulky, white powder,
with a slight odor of wintergreen and
a taste at first sweetish, then acrid. It
is soluble in 308 parts of water at 77°
F. and in 14 jxirts of boiling water,
and in 2 parts of alcohol, in 60 parts
of glycerin, and in 2 parts of olive oil
46
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
(with the aid of heat). Dose, 5 to 20
grains (0.3 to 1.3 Gm.) ; average, 7i/2
grains (0.5 Gm.).
Ammonii salicylas, U. S. P. (ammo-
nium saHcylate) [CcH4(OH)COO-
NH4], occurring in prisms or plates
or as a white, crystalHne powder,
odorless, with a saline, bitter taste
and sweetish after-taste. It is freely
soluble in water and alcohol. Dose,
3 to 15 grains (0.2 to 1 Gm.) ; aver-
age 4 grains (0.25 Gm.).
Sodii salicylas, U. S. P. (sodium sali-
cylate) [C6H4(OH)COONa], a white
microcrystalline or amorphous pow-
der, occasionally with a faint pink
coloration, and having a sweetish,
saline taste. It is soluble in 0.8 part
of water and in 5.5 parts of alcohol,
and also dissolves in glycerin. Dose,
5 to 20 grains (0.3 to 1.3 Gm.).
Strontii salicylas, U. S. P. (stron-
tium salicylate) [(C6H4(OH)COO)o-
Sr+2H20], a white, crystalline
powder with a sweetish, saline taste,
soluble in 18 parts of water and in 66
parts of alcohol. Dose, 5 to 20 grains
(0.3 to 1.3 Gm.).
Phenylis salicylas, U. S. P. (phenyl
salicylate; salol) [C6H4(OH)COOCg-
H5], a white, crystalline powder with
a slightly aromatic odor and taste,
practically insoluble in water, but
soluble in 5 parts of alcohol and freely
soluble in ether, chloroform, and oils.
Synthetic or from Gaultheria or Be tula.
Dose, 3 to 15 grains (0.2 to 1 Gm.) ;
average, 7^^ grains (0.5 Gm.).
Methylis salicylas, U. S. P. (methyl
salicylate ; an artificial or synthetic
oil of wintergreen) [CgH4(OH)-
COOCHoJ, a colorless liqvud with a
strong wintergreen odor, a sweetish
strongly aromatic taste, and a specific
gravity of 1.18. It is sparingly soluble
in water, but dissolves readily in alco-
hol. Dose, 5 to 20 minims (0.3 to
1.3 c.c). Chiefly usecf externally.
Salicinitm, U. S. P. (salicin) [C13-
llisOx), a glucoside obtained from
several species of the willow (Salix)
and poplar (Populus), occurring in
colorless, silky, crystalline needles,
prisms, or a white, crystalline powder,
odorless, but with a strongly bitter
taste. It is soluble in 21 parts of
water and in 71 parts of alcohol, but
is insoluble in ether and chloroform.
Dose, 10 to 30 grains (0.6 to 2 Gm.).
Oleum betulcc, U. S. P., VIII (oil of
betula; oil of birch), a volatile oil
obtained by maceration and distilla-
tion from the bark of the sweet birch,
Betula lenta. Consists mainly of
methyl salicylate. Dose, 5 to 20
minims (0.3 to 1.3 c.c). Chiefly
used externally.
Oleum gaulthericc, U. S. P. VIII (oil
of gaultheria or wintergreen), a vola-
tile oil di'stilled from the leaves of
Gaultheria procumbens, consists mainly
of methyl salicylate. Dose, 5 to 20
minims (0.3 to 1.3 c.c). Chiefly used
externally.
Spiritus gaulthericc, U. S. P. VIII
(spirit of gaultheria), made by mixing
5 parts by volume of oil of gaultheria
with 95 parts of alcohol. Dose, 30
minims (2 c.c).
Bismuth subsalicylate, physostig-
mine salicylate, quinine salicylate, and
cafifeine sodiosalicylate (N. F.) are
described in the articles on Bismuth,
Physostigma, Cinchona, and Caffeine,
respectively.
Among the salicylic preparations
recognized in the National Formulary
are: —
Lithii salicylas, N. F. (lithium
salicylate) [C6H4(OH)COOLi], a
white or grayish-white powder with
a sweetish taste, deliquescent in a
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
47
moist atmosphere. It is freely soluble
in water and alcohol. Dose, 5 to 20
grains (0.3 to 1.3 Gm.).
Elixir litliii salicylatis, N. F. (elixir
of lithimii salicylate). Dose, 2 flui-
drams (8 c.c), containing 10 grains
(0.6 Gm.) of lithium salicylate.
Elixir sodii salicylatis, N. F., similar
to the preceding.
Glyccrogclatimim acidi salicylici, N.
F. (glycerogelatin of salicylic acid),
containing 10 per cent, of the acid.
Used locally, being melted by gentle
heating and applied with a camel's
hair brush.
Liquor antisepticiis, N. F. (anti-
septic solution, Lister), containing 30
per cent, of alcohol, 2.5 per cent, of
boric acid, 0.12 per cent, of methyl
salicylate and of sodium salicylate, 0.6
per cent, of sodium benzoate, 0.5 per
cent, of eucalyptol, 0.1 per cent, of
thymol, and 0.03 per cent, of oil of
thyme. Dose, 1 fluidram (4 c.c).
Chiefly used locally.
Liquor antisepticiis alkalimis, N. F.
(alkaHne antiseptic solution), contain-
ing 15 per cent, of glycerin, 3.2 per
cent, of potassium bicarbonate and of
sodium borate, 0.8 per cent, of sodi-
um benzoate, 0.04 per cent, of oil of
gaultheria, and 0.02 per cent, of thymol,
of eucalyptol, and of oil of peppermint,
colored purplish red with cudbear; 6
per cent, of alcohol. Used locally,
diluted with 2 to 5 parts of warm water.
Pasta dnci, N. F. (Lassar's zinc or
zinc-sahcyl paste), containing 2 per
cent, of salicylic acid, with zinc oxide.
Used externally.
Piilvis antisepticus, N. F. (soluble
antiseptic powder), a mixture of
powdered boric acid, 86.6 per cent.;
zinc sulphate, 12.5 per cent.; salicylic
acid, 0.5 per cent.; phenol, eucalyptol,
menthol, and thymol, of each 0.1 per
cent. Used as dusting powder or in
5 per cent, solution.
Pulvis talci composites, N. F. (sali-
cylated talcum powder), consisting of
salicylic acid, 3 parts; boric acid, 10
parts, and powdered talc, 87 parts.
Used as dusting powder.
Mulla acidi salicylici, N. F. (salicy-
lated salve mull or ointment), a 10
per cent, preparation of salicylic acid
in benzoinated lard and suet, spread
on gauze or mull, to be applied to the
skin where penetration by the sali-
cylic acid is desired.
Mulla creosoti salicylata, N. F.
(salicylated creosote salve mull), like
the preceding, with addition of 20 per
cent, of creosote.
UNOFFICIAL PREPARATIONS.
— Among the unofiicial salicylic prep-
arations used internally are : —
Acetylsalicylic acid (aspirin) \Cq-
H4.0(CH3CO).COOH], occurring in
colorless, crystalline needles with an
acidulous taste, soluble in 100 parts
of water, and freely soluble in alcohol.
Salicylic acid is liberated from it in
the intestine. It causes less sweat-
ing than the ordinary salicylates.
Dose, 5 to 30 grains (0.3 to 2 Gm.).
Diaspirin (succinic ester of salicyl-
ic acid) [CoH4(COO.C6H4COOH)2],
a white powder with slightly acid
taste, sparingly soluble in water,
easily soluble in alcohol. Dose, 5 to
30 grains (0.3 to 2 Gm.). Stronger
than novaspirin, but has marked
sudorific power (Klaveness).
Novaspirin (methylene citrylsali-
cylic acid), a white, crystalline pow-
der with a faint acidulous taste,
scarcely soluble in water, freely solu-
ble in alcohol. Contains 62 per cent,
of salicylic acid. Dose, 10 to 30
grains 0.6 to 2 Gm.). Weaker in
4S SALICYLIC ACID, THE SALICYLATES, AXl) SALICIN (SAJOUS).
action than the preceding-, though bet-
ter tolerated l)y sensitive patients.
Salicylosalicylic acid (diplosal ;
salicylic ester of salicylic acid) [Cq-
H4(COO)OH.COOH.CcH4], a color-
less, tasteless powder, almost insolu-
ble in water, readily soluble in dilute
alkalies. It yields 1.07 times as much
jf the salicyl group in the organism
as salicylic acid itself, owing to the
fact that in its molecule two mole-
cules of salicylic acid are present in
condensed form, one molecule of
water (HoO) having been eliminated.
It is unirritating to the stomach and
is absorbed from the intestine. Dose,
5 to 20 grains (0.3 to 1.3 Gm.).
Antipyrin salicylate (salipyrin)
[CiiHioNoO.CcHiOH.COOH], a
white, crystalline powder, slightly
sweetish, soluble in 200 parts of w^ater,
readily soluble in alcohol. Acids
liberate salicylic acid from it, and
alkalies, antipyrin. Dose, 5 to 15
grains (0.3 to 1 Gm.).
Ferric salicylate (iron salicylate)
[Feo(OOC(OH)C6H4)3], a reddish-
brown or violet-gray powder, spar-
ingly soluble in water, readily soluble
in a solution of potassium bicarbonate.
Dose, 3 to 10 grains (0.2 to 0.6 Gm.).
Guaiacol salicylate (guaiacyl salicy-
late; guaiacol-salol) [C6H4.OH.COO-
(C6H4.OCH3)], a white, crystalline,
tasteless powder, insoluble in water,
soluble in alcohol. Decomposed by
alkalies. Analogous to phenyl sali-
cylate (salol). Dose, 5 to 15 grains
(0.3 to 1 Gm.).
Naphthol salicylate (betol ; naph-
thalol ; betanaphthyl salicylate ; naph-
thol-salol) [C6H4-OH.COO(CioH7)],
a white, shining, tasteless, crystalline
powder insoluble in water, with diffi-
culty solube in alcohol. Decomposed
when treated with alkalies. Split up
in the intestine by the pancreatic juice
and intestinal secretions. Dose, 4 to
8 grains (0.25 to 0.5 Gm.).
Quinine salicylate (saloquinine ;
salicyl quinine), a white, crystalline
powder, tasteless, insoluble in water,
moderately soluble in alcohol, and
containing 73.1 per cent, of quinine.
Dose, 5 to 30 grains (0.3 to 2 Gm.).
Santalol salicylate (santyl ; santalyl
salicylate), a yellowish oil with faint
balsamic odor and taste, soluble in
about 10 parts of alcohol. Split up in
the intestines, yielding 60 per cent, of
santalol (santal oil). Dose, 8 minims
(0.5 c.c).
Unofficial salicylic preparations
used externally : Ethyl salicylate (sal
ethyl) [C0H4.OH.c6o.C2H5], a col-
orless, volatile fluid with a pleasant
odor and taste, insoluble in water,
soluble in alcohol. Analogous to
methyl salicylate. ]\Iay be used both
externallv and internallv.
Mesotan (methyl-oxymethyl salicy-
late; ericin) [C6H4.0H.Cob(CH2.-
O.CH3)], a yellowish, faintly aro-
matic^ oily fluid, but little soluble in
water, soluble in alcohol, miscible
with oils. To be applied, diluted
with an equal volume of olive oil, to
the skin, avoiding friction, as meso-
tan is somewhat irritating.
Salophen ' (acet3'lparamidophenol
salicylate), a white, tasteless, crystal-
line powder, almost insoluble in cold
water, freely soluble in alkaline solu-
tions, and in alcohol. It contains 51
per cent, of salicylic acid. It is broken
up in the intestine, liberating salicylic
acid, and acetylparamidophenol.
Dose, 5 to 20 grains (0.3 to 1.3 Gm.).
Used externally in a 10 per cent, oint-
ment in itching skin affections.
Spirosal (monoglycol salicylate)
[C6H4.0H.COO(CH2.CH2.0H)], an
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 49
oily, almost odorless fluid, soluble in tation, and an appropriate amount
about 110 parts of water, freely solu- ordered mixed with some sparkling
ble in alcohol. To be applied to the water at each dose. An effervescent
skin undiluted, mixed with 3 parts of preparation may be secured by pre-
alcohol or 8 parts of olive oil, or in scribed equal amounts of salicylic
a 50 per cent, petrolatum ointment, acid and sodium bicarbonate in pow-
It is absorbed through the skin with- ders, to be dissolved in water and
out irritation and sets free salicylic taken when the effervescence begins
acid in the tissues. to subside. Small doses of sodium
INCOMPATIBILITIES.— Salicy- salicylate may be given in capsules,
lates are incompatible with mineral to be taken only during or after
acids, which set free the relatively meals. Strontium salicylate is pre-
insoluble salicylic acid by combining ferred by some to the sodium salt,
with the basic element. They are Oil of gaultheria (wintergreen) or
also incompatible with sweet spirit of methyl salicylate may also be sub-
niter, with lime-water, and with qui- stituted for it, given in elastic cap-
nine salts, ferric salts, lead acetate, sules during or after meals,
and silver nitrate in solution, as well The co-operative investigation of
as with sodium phosphate in powder the eft'ects of synthetic sodium sali-
form. Mixtures of quinine and cylate and sodium salicylate prepared
acetylsalicylic acid are dangerous, de- from natural sources, reported by
veloping after a time the poisonous Hewlett, and based on about 230 sep-
substance quinotoxin, which resem- arate observations, showed that, from
bles digitoxin in its action. This toxic the clinical standpoint there is no
change develops even more readily in essential difference between the two
a mixture of cinchona and acetyl- varieties of the drug. According to
salicylic acid, and also in elixirs and Pulliam, gastric irritation by sodium
syrups containing quinine in acid salicylate may be due to deteriora-
solution. tion, moisture gradually decomposing
MODES OF ADMINISTRATION, the salt with liberation of sodium hy-
— Salicylic acid, which is irritating to droxide and salicylic acid,
mucous surfaces, should always be Where sodium salicylate given as
given in solution, preferably with above described is badly tolerated by
potassium citrate or acetate, or am- the patient, resort may be had to such
monium acetate or phosphate, all of preparations as acetylsalicylic acid,
which increase its solubility in water, salophen, diaspirin, and novaspirin,
Or, it may be given in a syrup, which liberate the salicyl group only
flavored with compound spirit of in the intestine (and therefore have
lavender, or in elixir of orange. Pref- the disadvantage of acting more
arable to the acid, however, is sodium slowly and often less powerfully),
salicylate, which, though less irritat- or to salicin, given in generous dos-
ing, should likewise be given in solu- age. Or, the cutaneous, rectal, hypo-
tion. The salt may, for example, be dermic, or intravenous routes of ad-
prcscribed in 5 parts of Aqua men- ministration may be partly or wholly
thae piperitae or Aqua gaultherise, with relied on.
a little glycerin added to reduce irri- For application to rheumatic joints
8-4
50 SALICYLIC ACID, THE SALICYLATES, AND SALICLM (SAJOUS).
methyl salicylate or oil of gaultheria after it acts by the salicylate enema,
is generally used, either undiluted, on g'^'^'" ^ith the Davidson syringe and
, ^ 1 . ^. 1 I 1 • • „„ii a rectal tube inserted 6 to 8 inches,
absorl^ent cotton or rubi)ed ni ni small .r^, , • • , ,
i no dose varies with the weight and
amounts, or diluted with an equal part ,,^ .„,^, t,,^ severity of the case. The
of olive oil or 2 or more parts of first adult dose in men is usually from
petrolatum, chloroform liniment, or 8 to 10 Gm. (2 to 2>4 drams), in women
soap liniment. To prevent evapora- 6 Gm. {\y, drams). The drug to be
.■ r ,1 -1 -1 1 -11 .„ given is incorporated in 120 to 180
tion of the oils, oiled silk or some ,, . . ^ , .
. . . c.c. (4 to 6 ounces) of plain or starch
otiier impervious covering may be ^^^^^^ ^^-^^^ the addition of 1 to L5
used. Where these oils are not at Gm. (15 to 23 ounces) of opium tine-
hand, absorption of salicylic acid it- ture. The dose may be repeated
self may be secured bv rubbing in for within twelve hours, but usually a
a few minutes a tal^lespoonful of a daily enema suffices, with doses in-
. , . , . , . _ creasing perhaps from 30 to 50 per
mixture of 1 part of the acid m b ^^^^ j^j,y ^^^jj ^^e limit of tolerance
parts of alcohol and 10 parts of cas- is reached. The largest daily dose
tor oil (Cullen), or an ointment com- given was 24 Gm. (6 drams). The
posed of salicylic acid and oil of o"ly symptoms of salicylism usually
turpentine, of each 1 part, and hy- appearing were tinnitus and exces-
, , , r o ^T-. 1 N sive perspiration. The ready absorp-
drated wool-fat, 8 parts (Bracken). ,. u u ^ t ■
^ i- \ ' tion was shown by a strong ferric
The efficiency of either of these chloride reaction in the urine within
methods is shown by the disappear- thirty minutes. It would seem that
ance of joint pain and appearance of the greatest absorption of the drug
the drug in the urine within a few ^^ ^'^^hin twelve hours. L. G. Heyn
r^^-, ,1 c ^^ (Tour. Amer. Med. Assoc, Sept. 19,
minutes. Other local uses of sail- ,g. .
cylates are described in the section on
Therapeutics '^^^ hypodermic and intravenous
For rectal administration of sodium ^^^^^^ ^^^^'^ '^^e" ^^'^'^^^ o^' ^""'^^ §^oo^
salicylate the following formula, ''^^^^t^' ^^^ ^^^^ert and by Mendel,
recommended by Crouzet, may be Rubens, and Conner, respectively,
employed : Intravenous injection of salicylates
■D c J-- T 1 J- .% /le /" \ strongly recommended. The prep-
-r> Sodii sahcylafis 5ss (15 Gm.). . , .
A •,,;„• 7- //( r- ^ aration used consists of: —
Acacia piilveris 3j (4 Gm.).
Lactis fSiv (120 Gm.). Sodium salicylate 2 dr. (8 Gm.)
Fiat mistura. Caffeine sodiosalicyl.. . Yi dr. (2 Gm.).
T-i . ^ , ' 'its ' Sterile water 1^ oz. (45 c.c).
1 he mixture contains 30 grains
(2 Gm.) of sodium salicylate to the One-half dram (2 c.c) is injected
tablespoonful, is well tolerated, and *^.^*=^ ^ f'^- /' ^^l '"'"^^' J°^"*
, . , ,-7 • 1- pains and exudates disappear even
can be given ad libitum, according to , j- r i * ^ 4. ^
o ' ^ where ordinary salicylate treatment
the requirements of the case, with a f^iis. a single dose causes marked
glass syringe or the ordinary rubber improvement. None of the unpleas-
enema bulb. ant actions of salicylates are en-
Intrarectal administration of so- countered. Cases which do not react
dium salicylate recommended in re- are not rheumatic. This is the most
fractory cases of acute and subacute certain method of diagnosing the ex-
rheumatism from experience in 125 act nature of doubtful rheumatic
cases. A cleansing soapsuds enema cases, especially in diagnosing early
is given and followed immediately tuberculous and rheumatoid arthritis
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
51
from true rheumatic cases. F. Men-
del (Miinch. med. Woch., p. 165,
1905).
The writer injects 10 c.c. (2J^
drams) of a 20 per cent, sterilized
solution of sodium salicylate per 100
pounds of body weight for acute
rheumatic infections of joints, heart,
pericardium and pleura. He first uses
a hypodermic injection of cocaine
and fifteen minutes later injects in the
same spot the sodium salicylate. The
dose is repeated every twelve hours.
In severe cases with multiple lesions
15 c.c. (4 drams) to each 100 pounds
of body weight is advised. Within
three hours after the first injection,
pain, fever, joint stiffness and pulse
rate diminish. This improvement
continues if the injections are re-
peated every twelve hours, but if
omitted the conditions grow worse.
In chronic cases, 10 c.c. (2^ drams)
per 100 pounds of body weight of the
following oily solution are injected
every twenty-four hours: Salicylic
acid, 10 Gm. (2>^ drams) ; sesame oil,
80 Gm. (2% ounces) ; pure alcohol, 5
Gm. (l]4 drams); and gum camphor,
5 Gm. (1j4 drams). This is sterilized
before the alcohol is added. It must
not be exposed to the air, as the
alcohol will evaporate and the sali-
cylic acid precipitate. The effect in
chronic cases is more rapid when
multiple localizations of the rheu-
matic process exist than when one
joint is affected. In the former, pain
and stiffness usually improve after
the first injection; in the latter, after
the third. Addition of camphor (5
to 20 per cent.) was found beneficial
in stimulating the heart when the
pericardium or endocardium was in-
volved. With this method there is
entire absence of the toxic symptoms
seen when salicylates are given by
mouth. Siebert (Med. Rec, Mar. 11,
1911).
The rapidity of absorption of
sodium salicylate when given sub-
cutaneously is about the same as by
other routes, but its concentration in
the blood does not reach one-half of
that when it is given intramuscularly.
Sodium salicylate disappears from
the blood in ten hours when given
subcutaneously; if given per os it is
present in the blood after twenty-
four hours. E. Levin (Dent. med.
Woch., Dec. 19, 1912).
Administration of sodium sali-
cylate by intravenous injections is
safe, painless, and easily performed.
The drug seems to have a much more
pronounced analgesic effect than
when givent by mouth. The solution
for injection is made by dissolving
10 Gm. (2^ drams) of chemically
pure crystalline sodiuin salicylate in
50 c.c. (1% ounces) of distilled water,
freshly sterilized by boiling. In most
cases the dose has been either 15 or
20 grains (1 or 1.3 Gm.) and the in-
jections given at twelve- or eight-
hour intervals over a period of three
to six days. Occasionally, in robust
men, as much as 30 grains (2 Gm.)
have been given at a time, and as
much as 120 grains (8 Gm.) given in
the first twenty-four hours without
any unpleasant effects. The field of
indication for the intravenous method
includes cases in which the drug is
not well borne by the stomach; those
which show little or no improvement
under the usual methods and, pos-
sibly, cases of severe rheumatic in-
flammation of the eye. Conner (Med.
Record, Ixxxv, 323, 1914).
Case of a man of 25 with extremely
severe febrile rheumatism involving
all the joints, with mj'^ocarditis and
dyspnea; the stomach being abso-
lutely intolerant for the salicylates.
The writer gave an intravenous in-
jection of 6 c.c. (1^ drams) of a
mixture of 5 Gm. (1^4 drams) sodium
salicylate and 0.25 Gm. (4 grains)
caffeine in 25 Gm. (6 drams) distilled
water. The injection was repeated
daily for six days, increasing the
amount from 1.2 to 2 Gm. (20 to 32
minims). By the fourth day the man
was able to sit up, with normal tem-
perature, pulse 84, and no further
precordial distress. Cernadas (Se-
mana Medica, Dec. 23, 1915).
52 SALICYLIC ACID, THE SALICYLATES, AND SALICIX (SAJOUS).
Phenyl salicylate (salol), in its
usual dosage of 5 or 7^ grains (0.3
or 0.5 Gm.) every three or four hours,
exerts but little of the effect of sali-
cylates and rather acts like phenol,
which it gives ofif in the intestinal
tract. Large doses of phenyl sali-
cylate are, as a rule, to be avoided,
as they may induce symptoms of
phenol poisoning, and darken the
urine. It may be given in capsules,
in taljlets, or combined, for example,
with bismuth salts, in powders. It is
almost insoluble in the gastric juice,
and does not irritate the stomach.
CONTRAINDICATIONS. — Sali-
cylates are contraindicated except
sometimes when used for local pur-
poses, in middle-ear disease, and in
conditions associated with impaired
renal functioning, as in pregnancy
and chronic nephritis. Albuminuria
is a contraindication, except in renal
disturbance of rheumatic origin,
though in infections of the urinary
tract phen)^ salicylate is used. Sali-
cylates should not be administered to
pregnant women who have a tend-
ency to abort, nor in women with
metrorrhagia or menorrhagia. Where
there is circulatory depression, some
degree of caution as to the dosage of
salicylates is required.
Prolonged administration of sali-
cylates in large dosage is unwise,
causing debility, anemia, and a ten-
dency to hemorrhage from the mu-
cous membranes.
PHYSIOLOGICAL ACTION.—
Externally, salicylic acid is an irritant,
especially to mucous membranes.
Carefully applied to the skin it is
capable of softening the epidermis or
accumulations of horny epithelium
without inducing inflammation. It
also tends to arrest local sweating
and to promote the growth of normal
skin in chronic skin affections. It is
an antiseptic, stronger than acetani-
]ide and rivalling phenol, over which
it has the advantage of not volatiliz-
ing. The salts of salicylic acid are
less irritating than the free acid, and
also much less strongly antiseptic.
The liquid salicylates, such as methyl
salicylate and the oils of wintergreen
and birch, are, however, useful as
counterirritants.
General Effects. — Nervous System.
— The chief nervous effects of sali-
cylates is manifest in relief from pain,
probably due, as in the case of
acetanilide and its congeners, either
to constriction of vessels loco doleiiti
or to direct depression of the sensory
nerve-cells in the optic thalami.
Circulation. — Small doses, if any-
thing, slightly raise the blood-pres-
sure (chiefly by central vasoconstric-
tion) and accelerate the heart.
Large doses directly depress the
heart. The skin-vessels are dilated
by all doses. According to some the
number of leucocytes in the blood
shows a marked increase, returning
to normal, however, after a single
dose, within two hours.
Alimentary Tract.— ^Idiny of the
salicylates, especially the free acid,
act as irritants in the stomach.
Acetylsalicylic acid, phenyl salicylate
(salol) and salicin, however, may not.
passing through the stomach un-
changed and only setting free the
salicyl group in the intestine. Sali-
cylic acid tends to arrest ferment
action, interfering, therefore, with the
digestive processes. It is claimed
that intestinal putrefaction can be re-
duced with it, and, according to some,
large doses of salicylates stimulate
the formation of bile.
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 53
Temperature. — Salicylates lower the
temperature where there is fever, like
antipyrin, but act less strongly. The
effect is, at least in part, due to pe-
ripheral vasodilatation and sweating,
which increase heat loss. A direct
action on the heat centers has not as
yet been proved to occur.
Metabolism. — Augmented destruc-
tion of protein is caused by the sali-
cylates, as shown by a distinct in-
crease in the output of urea, uric acid,
and sulphur-bearing compounds in
the urine.
The increased output of uric acid
following salicylate medication is
due to a lowered threshold value of
the kidney, not only for uric acid,
but in all probability for other waste
products as well. Such being the
case, it may well be that the bene-
ficial effects resulting from the use
of salicylates in acute rheumatic
fever may, in part at least, be due to
a power possessed by this class of
drugs of increasing kidney permea-
bility, thereby facilitating the rapid
and more or less complete excretion
of the toxins which produce symp-
toms of these diseases. Denis (Jour.
Pharmacol, and Exper. Therap., Oct.,
1915).
Absorption and Elimination. — Sali-
cylates are rapidly absorbed from the
stomach and duodenum, and circulate
in the blood as salicylates of the alka-
lies. Excretion is also rather rapid,
and takes place chiefly through the
kidneys, which are irritated by large
doses and sometimes react, even after
moderate doses, by a diuresis. The
chief product in salicylic elimination
has long been considered to be salicyl-
uric acid, an inert compound with gly-
cocoll yielding a violet-red color with
ferric chloride. Studies by Hanzlik
(191.S), however, cast doubt upon the
elimination of salicyluric acid in man,
products free of glycocol), and pre-
sumed to be in part an impure sali-
cylic acid, being alone found. Small
amounts of salicylates ingested are
eliminated with the bile, sweat, and
mammary secretion.
UNTOWARD EFFECTS AND
POISONING. — Overdoses of salicylic
preparations produce symptoms simu-
lating cinchonism, viz., a feeling of
fullness in the head, tinnitus aurium
and, perhaps, slight dizziness. Other
signs of overdosage are gastric irri-
tability, nausea and vomiting; head-
ache ; inental dullness and apathy, and
impairment of hearing or vision, due
either to local circulatory modifica-
tions or to degenerative changes in-
duced in the cochlear or retinal nerve-
cells or in the optic nerve. After very
large doses complete deafness or
blindness may occur. According to
Drayer, 15 grains (1 Gm.) 4 times a
day for a week will often produce
deafness lasting four months.
In some cases of salicylism, mental
excitation is a feature — the "salicylic
jag." The cerebral symptoms are
similar to those induced by atropine,
— talkativeness and great cheerfulness
passing on to delirium with halluci-
nations and motor restlessness. De-
lirium is an especially common symp-
tom among drunkards. Mental dis-
turbance may persist a week or more.
A number of patients taking sali-
cylates experienced auditory hallu-
cinations. Long- forgotten memories of
certain sounds were aroused : the roar
of a certain water-fall, the singing of
birds heard in a certain garden, etc.
The drug reaching the cells seemed to
bridge the gap between unconscious
and conscious memories. Seitz (Corre-
spondenzbl. f. schweizer Aerzte, Apr.
1, 1909).
Poisonous doses of salicylic acid
induce l)urnin-- in the throat, nausea
54 SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
and vomiting, sometimes diarrhea;
special sense disturbances, sometimes
with mydriasis, ptosis, or stralMsmus ;
thirst; precordial oppression; feeble
heart action and vasomotor weakness;
sweating; marked dyspnea; prostra-
tion ; greenish urine, and occasionally
albuminuria, hematuria, or even sup-
pression of urine ; coma. Death, when
it occurs, is due to respiratory paraly-
sis, and may be preceded by general
convulsions.
A girl, aged 10 years, had been suf-
fering from acute rheumatism for
three days. Endocarditis developed.
A purgative was given and then IS
grains (1 Gm.) of sodium salicylate
with double that amount of sodium
bicarbonate every four hours, for
four days, when the child became
delirious and vomited twice. The
salicylate was withdrawn and the de-
lirium quickly passed ofif. On the
fourth day after admission the tem-
perature, pulse, and respirations were
normal.
Later, the patient again complained
of joint pains and salicylates were re-
sumed (7 grains — 0.45 Gm. — in water
3 times a day). After two days she
again vomited. There was no deliri-
um, but the urine contained sufficient
blood to give it a deep-red color. She
also complained of severe pain along
the left iliac crest, and there was
much tenderness in the left renal re-
gion. Salicylates being discontinued,
the urine was clear in four days, con-
taining neither blood nor albumin,
and the pain had also disappeared.
The pain was probably a "referred
pain" from the kidney. J. D. Mar-
shall (Lancet, Feb. 2, 1907).
The dosage of salicylic preparations
necessary to induce circulatory de-
pression is relatively large, 20 grains
of sodium salicylate, repeated at inter-
vals of two or three hours, rarely
having an appreciable action on the
pulse and blood-pressure.
The primary effect of salicylates is
on the temperature, which drops sud-
denly owing to increased heat radia-
tion through the dilated capillaries.
The resulting depression of the nerv-
ous system determines the collapse.
These drugs should be given in small
doses, frequently repeated, to avoid
rapid temperature reduction. Bovisoff
(Roussky Vratch, Feb. 23, 1913).
Experiments showing that solu-
tions of sodium salicylate gradually
deteriorate on standing, the loss be-
ing greater in the weaker solutions.
About 20 per cent, is destroyed in the
body, and 40 per cent, when there is
fever, alcoholism, morphinism, or
exophthalmic goiter. Hanzlick and
Wetzel (Jour, of Pharm. and Ex-
perim. Therap., Sept., 1919).
Erythema with edema, intolerable
itching and tingling of the skin, and
fever, have been catised by large doses
of sodium salicylate. Other possible
effects are transitory dark-colored
spots, ecchymoses, vesicles and pus-
tules.
According to Martinet, sodium sali-
cylate sometimes induces in children
symptoms similar to those of diabetic
acidosis. Sodium bicarbonate in large
doses and catharsis are advocated in
the treatment.
A chronic form of salicylic poison-
ing has been met with in persons ex-
posed to inhalation of the acid,
marked by a subacute inflammation
of the air-passages, sometimes with a
serious degree edema. In these in-
stances potassium iodide is beneficial.
Chronic absorption from food or drink
preserved with salicylic acid may re-
sult in constipation alternating with
diarrhea, mental depression, skin
eruptions, and albuminuria.
TREATMENT OF POISONING.
— The tinnitus caused by salicylic
acid may be relieved by a 20-grain
(1.3 Gm.) dose of sodium bromide. In
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 55
the treatment of salicylism, the giving
of large doses of sodium bicarbonate
has been recommended to hasten
elimination of the drug. The treat-
ment of severe acute poisoning is
largely symptomatic, cracked ice by
the mouth and an ice-bag or mustard
plaster over the epigastrium being
used to relieve vomiting, cold com-
presses being applied for headache,
veronal or opiates given for the rest-
lessness and delirium, and appropri-
ate stimulants for circulatory depres-
sion. As in other forms of acute
poisoning the stomach should be
thoroughly evacuated with the
stomach-tube or emetics and, if it
seems advisable, a purge given to
clear the drug from the intestine. For
further suggestions as to treatment
the reader is referred to the sections
on Poisoning in the articles on Ace-
TANILIDE, ACETPHENETIDIN, and AnTI-
PYRIN.
THERAPEUTICS.— Salicylic acid
and its salts are used for both general
and local effects.
General Uses. — As remedies in
acute rheumatism, the salicylates
hold first rank by reason of the
prompt relief of pain, fever and other
symptoms of this disease they afford.
Various methods of administration
have been suggested, some of which
are referred to in the article on Rheu-
matic Fever. Plehn, among others,
lays stress on adequacy of dosage,
giving even mild cases 15 grains (1
Gm.) of salicylic acid 6 times a day
(suspending the remedy at night),
until the temperature has remained
normal for three days, after which a
few 15-grain (1 Gm.) doses are given
daily for a week, the patient then re-
maining in bed three days more, with-
out the remedy. In women the dos-
age is made smaller — often only 5 and
sometimes only 3 doses a day at the
outset. With this treatment, Plehn
observed the development of valvular
disease in only 2 out of 319 cases
treated. Plehn's dosage, however,
seems somewhat excessive from the
standpoint of special sense impair-
ment and renal irritation. Sodium
salicylate is better tolerated by the
stomach than the free acid and may
be substituted for it for this reason.
Tinnitus should be regarded as a
warning signal against large dosag-e.
Homberger advises the combination
of sodium bicarbonate (1 or 2 parts)
with sodium salicylate, given in solu-
tion in a little water, the purpose
being to prevent liberation of the
more irritating salicylic acid from the
salicylate by the hydrochloric acid of
the gastric juice, and simultaneously
to accelerate absorption of the sali-
cylate by means of the carbon-dioxide
gas evolved. He al&o advises that the
drug be given between meals, when
there is least acid in the stomach, and
not too freely diluted, as a large quan-
tity of fluid will cause it to be retained
longer in the stomach. Salicylic
treatment in those with sensitive
stomachs can likewise be carried out
with acetylsalicylic acid (aspirin),
which sets free the salicyl group only
in the intestinal alkaline medium.
Klaveness prescribes this drug in 15-
grain (1 Gm.) doses every two or
three hours, combined, in persons in
whom circulatory weakness is sus-
pected, with V/2 grains (0.1 Gm.) of
powdered ergot. In children. Osier
is credited with recommending sali-
cin in full doses; Comby praises the
action of sodium salicylate in the dos-
age of 7 grains (0.5 Gm.) a day for
each year of the child's age. The
56 SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
rectal, intravenous, intramusclar, and
percutaneous methods of administer-
ing salicylates are also available.
Renal irritation from salicylates,
manifested in slight albuminuria,
sometimes with a few casts, is gen-
erally recognized to be a temporary
condition, though it may persist for
weeks and even be serious where
some degree of nephritis already ex-
ists. .Combination with sodium bicar-
bonate was found by Glaesgen to
obviate renal irritation by the salicy-
lates. Acetylsalicylic acid is held
by some to be non-irritating to the
kidneys.
In muscular rheumatism, including
lumbago, the salicylates are of value
in relieving the pain ; likewise in the
so-called "growing pains." In gonor-
rheal rheumatism their effect is less
marked. The pains of chronic fibro-
sitis are quickly relieved by sodium
salicylate combined with antipyrin
(Stark). In sciatica and other painful
rheumatic nervous conditions the sali-
cylates are also of distinct value. In
migraine, a combination of sodium
salicylate and potassium bromide,
given at the start of the attack, often
yields a gratifying result. In rheu-
matic uveitis and scleritis marked
benefit is obtained from 15-grain (1
Gm.) doses of the salicylates, given
4 times a day.
In rheumatic conditions associated
with anemia the writer uses the fol-
lowing mixture: In an 8-ounce (240
c.c.) bottle place 1 dram (4 Gm.) of
sodium salicylate and dissolve it in
about 2 ounces (60 c.c.) of water. Add
liquor ferri perchloridi (B. P.) Y2
dram (2 c.c), plus about an ounce
(30 c.c.) of water. This produces a
dark-purple mixture with a thick,
curdy precipitate. Then add 1 dram
(4 Gm.) of potassium bicarbonate
dissolved in 1 ounce (30 c.c.) of water,
and fill up the bottle to 8 ounces (240
c.c.) with water. The precipitate dis-
solves on the addition of the potas-
sium solution, and the result is a clear
claret-colored mixture of an agree-
able taste.
The mixture was found particularly
useful in a kind of sore throat ap-
parently of rheumatic origin (primary
or secondary) with slight redness and
pain, especially on swallowing. H.
Drinkwater (Liverpool Medico-Chir.
Jour., July, 1911).
For the relief of pain in general, the
acetyl preparations of salicylic acid,
such as aspirin and diaspirin, seem
more efficient than the other prepara-
tions. In neuralgia, the pains of tabes
dorsalis, and those of peripheral neuri-
tis, these drugs often prove of value.
In mild forms of dysmenorrhea,
acetylsalicylic acid is a particularly
efficient remedy. It may also be used
in acute and subacute pelvic cellulitis,
salpingitis, ovaritis, and parametritis.
In acute tonsillitis or peritonsillitis,
frequently rheumatic in nature, sali-
cylates are considered of value, re-
lieving pain and swelling, shortening
the period of illness, and perhaps
obviating suppuration if given early.
In addition to its internal use, garg-
ling with, c. g., lyi io2 drams (6 to 8
Gm.) of sodium salicylate in 6 fluid-
ounces (180 c.c.) of peppermint-water
(Cheveller), or direct application of a
salicylate to the tonsils (Fetterolf),
has been advised.
Salicylate of iron recommended in
erysipelas and acute tonsillitis. Care
should be taken in its preparation,
that the iron is added to the sodium
salicylate, otherwise the characteris-
tic reddish-brown precipitate does not
form.
For adults, the dose generally con-
tains 7H grains (0.5 Gm.) of sodium
salicylate and potassium bicarbonate,
and 7^ minims (0.45 c.c.) of the B.
P. liquor ferri perchlor. The solution
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 57
is of a clear violet color, and is quite
palatable, though it may be sweet-
ened if necessary. It is non-depres-
sant, non-constipating, and is a well-
marked febrifuge. The feces are
colored black.
In erysipelas the mixture acts with
the greatest rapidity, cutting short
the disease, which never lasts more
than 10 days, and in most cases is
cured in 3 or 4. After the first few
doses, there is a striking alleviation
of all pain. The drug is administered
every three hours, the treatment be-
ing commenced with a purgative, such
as calomel. As a rule, within 24
hours the temperature is normal, the
disease has ceased to spread, and the
patient feels better.
The cases of acute tonsillitis in
which salicylate of iron has an ex-
cellent action are probably those of
streptococcal origin. It acts very
quickly; if, after 3 days, there is no
marked improvement, it is not worth
while continuing. In a recent out-
break of sore throats at a school, the
drug was markedly successful in
about 50 per cent, of cases.
In cases of erysipelas of great
severity, the writer often adds twice
the usual amount of iron, which pro-
duces a very dark solution but no
precipitate, and is much stronger in
its action on the disease. M. C. S.
Lawrance (Practitioner, Mar., 1913).
In influenza or grippe, Stark admin-
isters the following after a mercurial
purge :—
R Sodii salicylatis.
Potass a hicarbona-
t'ls aa gr. X (0.6 Gm.) .
Tiiictitrtc inicis vom-
ica: TTL X (0.6 c.c.) .
Aq. chlorof. ..q. s. ad fSj (30 c.c).
M. Sig. : Every two to four hours.
Good results in pneumonia of in-
fluenzal origin, in that succeeding
measles, and in pharyngitis, laryn-
gitis, and bronchitis, Ijy bical applica-
tion of a 10 per cent, solution of sal-
icylic acid and of castor oil, respec-
tively, in 90 per cent, alcohol. In the
pneumonic cases a compress moist-
ened with the solution was placed over
the entire back, covered with imper-
meable material, and held in place by
a bandage. The dressing was renewed
whenever it became dry. A prompt
and very favorable influence upon the
cough, temperature, pulse and res-
piration was noted. L. G. Boutchin-
skaia-Yourchevskaia (Semaine med.,
Sept. 11, 1912).
In acute coryza, the same author
recommends the following : —
R. Sodii salicylatis gr. x (0.6 Gm.).
Spiritus amnioiiicc aro-
matici f3ss (2 c.c).
Tincturcc belladonmr
foliorum m. v (0.3 c.c.) .
Aq. chlorof. ..q. s. ad f5j (30 c.c).
M. Sig. : Every four hours.
Stark has also found the drug use-
ful in mumps, in puerperal fever, and
in "bilious headache," in the latter
condition combined with potassium
bromide.
In gout, salicylic acid, though in-
ferior to colchictim, may be of value
for a short time. It was found by
Fine and Chace (1915), to increase
the elimination of uric acid, some-
times even more than atophan. In
phosphaturia, sodium salicylate will
clear up the urine and arrest the reflex
nerve pains.
In pleural effusion, 30 to 60 grains
(2 to 4 Gm.) of sodium salicylate are
credited with some power to promote
absorption of the effusion.
In diabetes mellitus, von Noorden
considers sodium salicylate the most
useful of the drugs, with the excep-
tion of codeine and other nerve
sedatives.
Chibret found sodium salicylate in
a daily dosage of 1 dram (4 Gm.) of
some value in l)ringing symptomatic
relief in exophthalmic goiter. Monae-
Lesser observed that the administra-
58 SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS).
tion of 3 or 4 15-i^rain (1 Gm.) doses
of sodium salicylate in renal and hep-
atic colic assisted the action of opiates
and, by relaxing the channels, favored
passage of the stones. The same
author advises the giving of sodium
salicylate by the mouth or rectum (15
grains every three hours) in cystitis
and acute prostatitis, and treats acute
ascending cellulitis of the extremi-
ties by administering this salt intern-
ally and applying locally an ointment
consisting of magnesium carbonate,
resorcinol, and lanum.
The value of phenyl salicylate
(salol) as an antiseptic acting in the
urinary passages is well known. A
dosage exceeding 30 grains (2 Gm.)
a day is rarely necessary, and is, in
fact, likely to produce untoward re-
sults. The drug should, therefore,
ordinarily not be employed in acute
rheumatism. It is of value, however,
in gonococcal urethritis, in pyelitis,
and in certain forms of cystitis.
For purposes of intestinal antisep-
sis, phenyl salicylate is likewise the
most useful drug of this group, hav-
ing the added advantage of not up-
setting the stomach. Diarrhea due to
an acute infection or toxic food is
frequently arrested by phenyl salicy-
late, which may be given alone in 5-
or yyz- grain (0.3 to 0.5 Gm.) doses in
capsules or tablets or with 2 or 3
parts of bismuth subnitrate in pow-
ders. Bismuth subsalicylate may be
substituted for the last-named com-
bination, but its antiseptic effect is
far inferior, ownng to the absence of
phenol.
Local Uses. — In subacute and
chronic eczema, salicylic acid often
gives excellent results, more particu-
larly in the "rubrum" and squamous
varieties, or where there is consider-
able Assuring, e.g., on the dorsa of the
liands and in the flexures of the joints.
An ointment containing 4 to 8 per
cent, of salicylic acid in either petrola-
tum, hydrated wool-fat, or zinc-oxide
ointment should be used in such cases.
In eczema of the face, in the weeping
stage, or in not too extensive ery-
thematous or pustular eczema, the fol-
lowing is of value : Salicylic acid, 5
to 10 grains (0.3 to 0.6 Gm.) ; pow-
dered starch and zinc oxide, of each 2
drams (8 Gm.) ; petrolatum, ^ ounce
(15 Gm.).
In psoriasis salicylic ointments are
of value, especially to remove the
scales. Crocker recommends salicy-
lates internally in extensive but re-
cent psoriasis guttata. In pityriasis
capitis with marked desquamation
Cantrell found useful a weak emul-
sion of salicylic acid in water with
mucilage of acacia. Pityriasis rubra
also improved under mild salicylic
ointments, and mild cases of ichthyo-
sis were likewise benefited. Lentigo
was usually cured by strong salicylic
applications. Indurated, papular acne
Avas greatl}^ improved, and seborrhea
of the scalp, chest, or nasal orifices
favorably influenced. Among the
other skin conditions in which salicy-
lic acid has proven of use are erythe-
ma multiforme, erythema nodosum,
lupus erythematosus, and miliaria.
Erythema following horseback riding,
or intertrigo, may be relieved with a
2 per cent, salicylic ointment.
The itching of urticaria may be
allayed with a dusting powder com-
posed of salicylic acid, 1 part; zinc
oxide, 3 parts, and powdered starch,
6 parts. In chronic urticaria, the in-
ternal use of 20-grain (1.3 Gm.) doses
of sodium salicylate is also recom-
mended. For pruritus of the vulva
SALICYLIC ACID, THE SALICYLATES, AND SALICIN (SAJOUS). 59
and anus the following' may be used : any part of the growth remains, the
Salicylic acid, white wax, of each 2 treatment may be resumed and con-
drams (8 Gm.) ; cacao butter, 5 drams tinned for three days. This, however,
{20 Gm.) ; oil of nutmeg, 3^ dram is not often necessary.
(2 CO.). Soft chancres and venereal sores
In ordinary ringworm (tinea cir- may be dressed with the following
cinata) a solution of 10 grains (0.6 ointment : Salicylic acid, 20 grains
Gm.) of salicylic acid in ^^ ounce (15 (1.3 Gm.) ; alcohol, 45 minims (3 c.c.) ;
Gm.) of collodion is rapidly curative benzoinated' lard, 2 ounces (60 Gm.).
where the condition is not too long As a dusting powder, 1 part of the
standing. acid may be mixed with 8 parts of
In hyperidrosis of the feet, hands, powdered starch or chalk,
or axillae, a mixture of equal parts of A 1 : 1000 solution of salicylic acid
powdered salicylic acid and talc or has been employed as a nasal douche
starch will remove odor and tend to in chronic ozena. In chronic middle-
arrest the trouble. ear suppuration Foltz has used with
Where there is a tendency to occlu- satisfaction insufflations of 1 part of
sion of the ducts of sweat-glands or powdered salicylic acid with 6 parts
other follicles, mild salicylic oint- of boric acid.
ments are of value to prevent or over- Thiersch's solution, a non-toxic
come blockage. fluid available for general antiseptic
For corns, a saturated solution of purposes, consists of salicylic acid, 1
salicylic acid in collodion, the creosote part ; boric acid, 6 parts ; dissolved in
salicylic plaster mull of Unna (6 to water, 500 parts.
10 parts of the acid and 1 to 2 parts Application of dry powdered sali-
of creosote spread upon gutta-percha), cylic acid to suppurating and infected
or the following combination, may be wounds gives excellent results, caus-
relied on to produce the desired '"^ liquefaction and prompt disap-
pearance of the scab or slough, leav-
SO enmg. ^^^ ^ clean, bright-red, granulating
IJ Acidi salicylici gr. x (0.6 Gm.). surface which heals rapidly. Offen-
Olei terebinthincE rec- sive odors disappear within 24 hours.
tificati rn,v (0.3 c.c). It causes no pain or irritation. Doses
Acidi acetici glacialis ni.ij (0.12 c.c). of 3 to 5 gains (0.2 to 0.3 Gm.) in
Cocaina- hydrochlo- milk or bismuth suspension give fa-)
ridi gr. ij (0.12 Gm.). vorable results in typhoid fever. In
Collodii TTi^c (6 c.c). vitro, 0.2 to 0.5 per cent, of the acid
M. Sig. : Apply locally. inhibits or destroys Shiga's dysentery
T- , r • -1 bacillus, the B. typhosus, staphylo-
l^or removal of warts, smular prep- ct ,.* ^ u
' ^ ^ coccus, streptococcus pyogenes, B.
arations are advantageously used. A diphtheria, pneumococcus, and B. tet-
mixture of salicylic acid and lactic ani. A. Wilson (Brit. Med. Jour.,
acid, of each yi dram (2 Gm.) in 1 Feb. 20, 1915).
fluidounce (30 c.c.) of flexible collo- ^- E. de M. Sajous
dion may be applied to the summit ^ ^^^
of the wart with a match-stick night ^- ^- ^^ ^- Sajous,
J • r r -J * Philadelphia,
and mornmg for hve or six days.
Soaking the part in water will then SALINE INFUSION. See Infu-
cause detachment of the slough. If signs Saline.
60
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS).
SALIVARY GLANDS, DIS-
EASES OF. —X EROSTOMIA
(DRY MOUTH).— Symptoms.—
Arrest of the salivary or l^uccal secre-
tions was first studied l)y Hutchin-
son, in 1887. Since then about 40
cases have been recorded. The
tongue appears red, devoid of epi-
tlielium, cracked, and absolutely dry.
The inside of the cheek and the hard
and soft palates are also dry, and
the mucous membrane is smooth,
shining-, and pale (Seifert). Diminu-
tion in the nasal and lachrymal secre-
tions has also been noted, as well as
dryness of the skin and crumbling'
or falling out of the teeth. The
urine is normal. The general health
and the digestion are unimpaired,
but swallowing and articulation are
difficult, owing to the absence of
moisture. The disease usually reaches
its greatest intensity rapidly, and
may then remain without change for
years. It usually persists until the
patient dies.
Etiology and Pathology. — Xero-
stomia is almost always met with in
women, and about one-half of the
cases occur in subjects past 50
years of age. It sometimes follows
a shock. It is usually ascribed to
defective nerve-function, many pa-
tients showing distinct evidences of
nervous disturbance: hysteria, hypo-
chondria, anuria, etc. In some it ap-
pears to result from mere arrest of
function without impairment of the
general health. In 36 cases studied
by A. J, Hall the state of the salivary
glands and ducts was as follows: In
8 cases the parotids were enlarged,
either equally or unequally ; in 3
they were tender and painful ; in 4
they were not so, and in 1 the gland
ulcerated through into the mouth. In
5 cases enlargement varied from time
to time; in 1 of these enlargement
was most marked at the menstrual
period. With 1 exception, other
neighboring salivary glands were
not enlarged.
Treatment. — Pilocarpine has been
used with some success in these
cases, but the condition usually re-
curs. Blackman employs the drug in
/JO- to i/io-grain (0.003 to 0.006 Gm.)
doses, in a gelatin lamella, which
is placed on the tongue and moistened
with water.
PTYALISM. — Excessive secretion
of saliva occurs as a symptom of
rabies, the various forms of stomati-
tis, especially the mercurial form,
dentition, various gastric disorders,
etc. ; but as an idiopathic disorder it
is rarely met with. It is often ob-
served in neurotic subjects, especiallv
children, and usually disappears after
a few years, when the development
of the subject has become equalized.
It occasionally attends pregnancy
{q. z'.), and may occur during men-
strual periods and various febrile
disorders, particularly smallpox. The
effects of pilocarpine, mercury, iodine,
copper, and other agents in causing
ptyalism are well known.
Treatment. — The general health
r-equires attention, the idiopathic form
I'cing in realitv a manifestation of
debility. Weak astringent washes,
or a saturated solution of potassium
chlorate, may be tried. The galvanic
current, the positive pole being ap-
plied in the mouth while the latter is
full of water, the negative pole being
placed over the thyroid cartilage,
may prove of value if used daily.
SALIVARY CALCULUS.— Sali-
varv concretions of various sizes
sometimes form in the parotid gland
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS).
61
and its duct, — Stenson's, — causing in-
flammation of the organ, retention of
saliva, and enlargement of the organ.
The majority of calculi, however, are
found in Wharton's duct: the duct
of the maxillary gland. Foreign
bodies — which, as shown by Desmar-
tin, frequently enter Wharton's duct
— often act as nuclei. Klebs and
Waldeyer contend that masses of
micro-organisms are the most com-
mon causes of salivary calculi, the
phosphates and carbonates of lime,
magnesia, soda, etc., being deposited
around them. The stones may be-
come as large as eggs, and multiple,
and are occasionally facetted. In
some cases the inflammatory phe-
nomena proceed to abscess-formation,
and, spontaneous rupture taking
place, a salivary fistula is formed.
In the case of Stenson's duct the
opening is opposite the second molar
of the upper jaw. Wharton's duct
opens beneath the tongue, under the
frenum. Both openings can be pene-
trated with a probe, or a fine needle
may be inserted into the mass and
its contents thus recognized.
Treatment. — It is sometimes pos-
sible to remove a small calculus
through the canal ; but, as a rule, it is
necessary to thoroughly anesthetize
the part with cocaine and to remove
the mass by an incision through the
oral tissues.
TUMORS OF THE SALIVARY
GLANDS.— Cysts.— Cystic dilatation
of the parotid and maxillary glands
or of tlieir ducts is occasionally ob-
served, as a result of a superficial
inflammatory process or of cicatricial
stenosis of the orifices. In a case
noted by Stubenrauch the growth —
a parotid cy<,t — was found studded
with tubercular nodules. Stenson's
duct may become inflated with air
through forcible air-pressure — such
as that accompanying the playing of
wind-instruments, glass-blowing, etc.
— and simulate a cyst.
In many of these cases it is neces-
sary to remove the sac wall after
evacuating the contents by incision.
Tumors of the Parotid. — Tumors
of the parotid are often the result
of implication of the glandular tis-
sues in neoplasms of neighboring
structures. They may arise in the
gland itself, however. Almost any
variety of growth, especially ade-
noma, fibroma, chondroma, myx-
oma and the malignant varieties —
sarcoma and carcinoma — may be
encountered.
The removal of the entire gland
for large malignant growths necessi-
tates a grave operation, owing to
the proximity and frequent involve-
ment of the external carotid, the in-
ternal jugtflar vein, and other im-
portant vascular and nervous struc-
tures. For this reason, large malig-
nant neoplasms are removed with
difficulty and often imperfectly. Arr
old and good rule in such cases is to
remove movable growths: i.e., those
which are not firmly fixed to the un-
derlying tissues. Benign tumors can
usually be successfully extirpated.
After the first free incision is made
the mass should as much as possible
be removed by the fingers. The
facial nerve and the temporomaxillary
are thus less exposed to injury.
Tumors of the Maxillary Gland. —
This gland may be the seat of any
of the forms of tumor met in the
parotid, but, like it, is often involved
in growths that develop in the neigh-
boring structures, especially carci-
noma of the inferior maxillary. The
62
SALlVAkV GLANDS, DISEASES OF (CRANDALL AND MILLS).
mass usually projects beneath the
jaw. The removal is not as difficult
as is the case of tumors of the parotid,
the facial and ling-ual arteries, which
are easily tied, and the ling-ual and
hypog-lossal nerves, which can easily
l>e avoided, offering- no obstacle to a
thoroug-h operation. Here, also, how-
ever, it is always best to use the fin-
eers to decorticate, as it were, the
g-rowth after incision of the superficial
tissues.
PAROTITIS. — Inflammation of the
parotid gland.
Definition. — Parotitis is usually an
infectious disease {infectious paro-
titis), but it may result from injury
{traumatic parotitis) or from the ex-
tension of inflammatory or malig^nant
.processes in adjacent tissues {irrita-
tive parotitis).
TRAUMATIC PAROTITIS.— Inflam-
mation of the parotid gland may cer-
tainly result from injuries of suf-
ficient severity to cause an effusion
of blood into the gland or the tis-
sues surrounding it. It may also re-
sult from burns or the application
of caustics. While micro-organisms
may take part in the process, the
condition is quite different from in-
fectious or septic parotitis. Unless
infected with septic germs, suppura-
tion is not common.
INFECTIOUS PAROTITIS. — Two
forms of parotitis occur as the direct
result of germ invasion: 1. Mumps;
epidemic parotitis. 2. Metastatic, symp-
tomatic, suppurative, or septic parotitis.
The writers observed 38 cases in
which extreme swelling and pain in
one or both parotid glands had fol-
lowed typhus or relapsing fever at a
French hospital in Roumania in 1917.
The parotitis seemed to be more
common after typhus, and gangrene
from arteritis after relapsing fever.
but these complications occurred in
some of both. They recall that it is
due to secondary infection, strepto-
cocci predominating. Bonnet and de
Nabias (Lyon Chir., Mar.-Apr., 1919).
1. Mumps. — Mumps is an acute,
infectious, contagious inflammation
of one or both parotid glands, or
other salivary glands, usually occur-
ring epidemically. Although inflam-
mation of the parotid glands may be
caused by various germs, the disease
commonly known as mumps gives
every indication of being a specific
^disease. A period of incubation, the
method of invasion, and the definite
course pursued mark the disease as
a specific fever. No specific germ,
however, has as yet been discovered.
Several micro-organisms have been
isolated and held by their discover-
ers to be the causative germ of the
disease. The last of these at the
present writing was a micrococcus
described by Merelli, of Pisa, to
which he g'ave the name of Micrococ-
cus tragcnus. The correctness of this
view has not yet been confirmed by
other observers.
In 1908 Granata concluded that the
virus of mumps may be of the filter-
able type. • However, neither he nor
Nicolle and Conseil, who injected
bacteria-free fluid from the parotids
in cases of human parotitis, repro-
duced the disease satisfactorily.
The writer succeeded in reproduc-
ing the chief organic lesions of paro-
titis in animals by means of filtered ex-
tracts of saliva from human patients.
The active agent in the infectious
saliva was found to be neutralized by
the serum of an animal that had sur-
vived the injection of testicular and
parotid emulsions, while the serum
of a normal animal had no such
power. Various facts suggested the
presence of a minute filterable virus.
Martha Wollstcin (Jour. Exper. Med.,
xxxiii. 353, 1916).
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS),
63
In S cases of mumps a Gram posi-
tive diplococcus was isolated from the
spinal fluid, the blood, and a lymph
gland by the writer. The injection of
the organism into the testicle of a
rabbit produced severe orchitis in 10
days. These findings confirm the
earlier reports of similar organisms
from cases of mumps, and it appears
probable that mumps is caused by a
Gram positive diplococcus and not
by a filterable virus. R. L. Haden
(Amer. Jour. Med. Sci., November,
1919).
Incubation. — The period of incu-
bation is exceedingly variable. That
most commonly observed probably
lies between, 16 and 20 days. It has
been given by different authorities as
follows: Flint, 10 to 18 days; Holt,
17 to 20 days; Ashby and Wright,
14 to 21 days; Smith, 19 to 21 days;
Jacobi, 2 to 3 weeks; Dukes, 16
to 20 days; Dauchez, 15 days; Roth,
18 days; Henoch, 14 days.
Symptoms. — Premonitory symp-
toms are usually slight or entirely
wanting. In rare cases malaise and
headache precede the actual onset for
a week. There is frequently a period
of invasion lasting from twelve to
twenty-four hours, marked by fever-
ishness, headache, muscular pains,
anorexia, and perhaps vomiting. In
very many cases the local symptoms
are the first to appear. Pain is usu-
ally the first of these. It is stitch-
like in character and is located in
the parotid gland, but radiates into
the ear. It is increased by pressure
and by all movements of the jaw. It
increases in severity and in many
cases becomes very intense. In other
cases spontaneous pain is not felt, it
being developed only upon pressure
or movements of the jaw. Rilliet de-
scribes three painful points : one at
the level of the temporomaxillary ar-
ticulatiorv; one below the mastoid
apophysis; the third over the sub-
maxillary gland. Swelling soon en-
sues, and first appears in the depres-
sion between the mastoid process and
the ramus of the jaw, forcing the
lobe of the ear outward. At first the
parotid gland alone is involved and
the swelling assumes the character-
istic triangular shape, the upper
angle being just in front of the ear.
As the surrounding tissues become
involved, the triangular shape is
lost. The cheeks, side of the neck,
and regions behind the ear become
swelled, the swelling in some in-
stances extending almost to the
shoulder. The tumefaction in front
of the ear, however, remains as one
of the distinctive marks of parotitis.
The swelled area is often reddened,
but more commonly the skin is nor-
mal in color and appearance. Over
the gland the swelling is elastic to
the touch, but the surrounding tis-
sues are usually edematous and have
a doughy feeling and may even pit on
pressure.
The pharynx and tonsils are fre-
quently involved by the edema, caus-
ing much discomfort. When the dis-
ease is unilateral, the head is inclined
toward the affected side. When both
sides are involved, the head is held
rigidly upright, as every movement
causes pain. The appearance is char-
acteristic and striking, and in ex-
treme cases the patient becomes al-
most unrecognizable.
Both sides are usually affected be-
fore the attack runs its course. They
may be attacked simultaneously, but
more frequently the inflammation oc-
curs upon one side a day or two be-
fore it appears on the other. Of 228
cases reported by Holt, both sides
64
SALIVARY GLANDS, DISEASES OI- (CRANDALL AND MILLS).
were affected in 215. The interval is
sometimes a week or more, but more
commonly it is not more than three
days. In unilateral mumps the left
side is affected more frequently than
the right.
The swelling- commonly reaches its
height on the third day ; it remains
stationary for two or three days, and
then subsides witli greater or less
rapidity. The edema of the sur-
rounding tissues is the first to dis-
appear. After the edema has gone
the gland is sometimes slow to gain
its normal dimensions. Seven to ten
days are required for the disease to
run its course, but the duration of the
illness depends also upon the interval
between the involvement of the two
sides. A patient of my own was con-
fined to the house almost a month.
The parotid on the right side was
attacked a week after that on the left,
and this was followed by orchitis on
the eighteenth day.
The other salivary glands are not
infrequently involved, and in rare
cases the submaxillary glands alone
are affected.
The secretion of saliva is usually
diminished, but occasionally it is in-
creased. This, together with the
painful swelling of the face, edema of
the throat, and constitutional symp-
toms, renders the patient extremely
wretched. Attempts to examine the
throat are often futile, the patient
being scarcely able to open the mouth.
He will make no attempt at masti-
cation and refuse food, owing to the
pain during deglutition. These symp-
toms are especially prominent when
the tonsils are involved. Even speak-
ing is then painful. Although the
swallowing of acids commonly causes
severe pain, it does not always do so,
and the popular belief that it is an
infallible sign of mumps is erroneous.
Constitutional symptoms are usu-
ally not severe. The fever is rarely
high. The temperature ranges in
ordinary cases from 100° to 102° F.
(37.8° to 38.9° C). It frequently does
not go above 101° F. (38.3° C.) at any
time during the attack, but in severe
cases it may reach 104° F. (40° C.)
or even more. Other symptoms are
those .common to all febrile condi-
tions. When the swelling is extreme,
pressure upon the vessels of the neck
may cause headache and marked
cerebral disturbance. Delirium is
sometimes due to this cause. The
severity of the disease varies greatly
in different epidemics. In some the
children are but slightly ill ; in others
they are quite seriously so when the
disease is at its height, and are left
weak and anemic.
The blood in mumps shows defi-
nite changes in the corpuscular con-
tent consisting (a) in a slight in-
crease in the total number of leuco-
cytes, and (b) in a lymphocytosis
which is both relative and absolute.
The lymphocytosis is present on the
first day of the disease and persists
for at least fourteen days. The oc-
currence of orchitis does not invari-
ably alter the blood-picture. The
blood changes are of distinct diag-
nostic value in differentiating mumps
from other inllammatory swellings
of the parotid or submaxillary sali-
vary glands and from cases of
lymphadenitis. A lymphocytosis of
the cerebrospinal fluid occurs when
mumps is complicated by meningitis
or by lesions affecting the cranial
nerves. It has, however, also been
found in cases of mumps which have
presented no clear clinical symptoms
of any organic lesion of the nervous
system. From a consideration of the
blood and cerebrospinal fluid, one is
justified in assuming that the virus
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS).
65
of mumps excites an inflammatory
reaction, the characteristic feature of
which is a great aggregation of
lymphocytes. A. Failing '^Lancet,
July 12, 1913).
Diagnosis. — The rapid onset and
almost equally rapid subsidence of
the glandular enlargement is a most
characteristic feature of mumps.
This, together with the location of
the tumor and its peculiar shape and
large size, distinguishes it from
acute enlargement of the lymphatic
nodes, as well as chronic malignant
growths. The location of the tumor
is usually sufficient to distinguish it
from the cervical swellings of scarlet
fever and diphtheria, but examina-
tion of the throat should always be
made in cases in which there is the
slightest doubt.
Etiology. — Although mumps is
spread by contagion, susceptibility is
probably less than to any of the
other contagious diseases. Close
contact is usually necessary. The
disease is rarely carried from one
person to another by a third, but that
is known to have occurred. The dis-
ease is rare under 4 years and very
few cases in infants have ever been
reported. It is rare in adult life and
still more so in old age. It is most
common between the ages of 5
and 14.
The exact period of infection is
doubtful. Contagion is possible from
the first symptoms or even before the
swelling of the glands has appeared.
The power of infection seems to con-
tinue in some cases for several days
after the first symptoms have disap-
Epidemics of mumps occur more
commonly in the fall and spring than
at any other season. They vary
greatly in frequency of occurrence
and the extent of territory involved,
occurring in some localities almost
annually and in others only at inter-
vals of many years. The infective
power of the disease varies decidedly
in dififerent epidemics. Epidemics of
measles and mumps are frequently
associated.
Recurrence of mumps is uncom-
mon, but is not unknown, as my own
personal experience has positively
demonstrated.
Pathology. — Opportunity for post-
mortem study of parotitis is so rare
that its pathology is not yet fully un-
derstood. So far as known, patho-
logical changes are confined to the
salivary glands. Infection probably
takes place through the salivary
ducts, the gland-substance being first
involved. The periglandular tissue
is involved secondarily. In those
cases in which pathological exami-
nations have been made, the salivary
ducts have been found to be occluded
by swelling and inflammation of
their walls. The gland itself is
hyperemic and edematous. Suppu-
ration is rare and probably does not
occur in simple parotitis. Its occa-
sional occurrence is probably due to
pyogenic bacteria which have found
admission with the specific germs.
Complications and Sequels.
— Among young children complica-
tions are rare. Suppuration occurs in
about 1 per cent, of the cases, accord-
peared. Isolation, to be effective, ing to Holt, and is usually due to
must be continued for at least a week some accidental infection by pyogenic
after the swelling has entirely sub- germs. Deafness, due not to otitis
sided, or nearly three weeks from the media, but to disease of the auditory
first symptoms. nerve, has been reported in a very
8-6
(£
SATJVARV GLANDS, DISEASES OF (CRANDALL AND MILLS).
few cases. It is usually unilateral
and permanent. Facial paralysis,
multiple neuritis, and other nervous
disorders also occur in very rare in-
stances, and nephritis is not unknown
as a sequel. Meningitis and ocular
complications have also been ob-
served. Pancreatitis with epigastric
and vomiting- and glycosuria are not
uncommon complications.
The writer has seen many cases
of epigastric pain with vomiting in
the last stages of mumps. Out of 20
cases in one school, 10 followed this
course, and all showed tenderness to
pressure over the pancreas. Fox re-
ports a similar case: On the fifth day
of mumps a boy developed fever,
epigastric pain, and vomiting, and a
deep-seated swelling was felt in the
epigastric region. There was no
sugar in the urine, and the boy re-
covered. Cecil Reynolds (Brit. Med.
Jour., ii, 352, 1910).
Pancreatitis may be one or the sole
manifestation of the acute infection
called epidemic parotitis. The pain
and protrusion of the stomach region
which some writers have explained
as acute mumps pancreatitis may
have been merely an acute gastritis
as a manifestation of the infectious
process. L. Cheinisse (Semaine med.,
Feb. 21, 1912).
In the pancreatitis of mumps, pain
is the most noteworthy symptom;
tenderness in the region may persist
after other symptoms have disap-
peared. Constipation, followed by a
colliquative diarrhea, is common.
Fever, epistaxis, profuse sweating,
irregular pulse, and the facies of
grippe are also noted. Jaundice may
supervene. The diagnosis, in view
of the very obvious mumps, is there-
fore not difficult. The prognosis is
favora1)le. Raymond (Paris med.,
Aug. 3, 1912).
A most peculiar but characteristic
complication is orchitis. It is most
common in adolescents and adults
and is extremely rare ia children.
Among 230 cases of mumps Rilliet
and Barthez saw but 10 cases of
orchitis, only 1 being under 12 years.
Its frequency undoubtedly varies
in different epidemics. The disease
is a true orchitis, but epididymitis
in rare cases occurs either alone or
complicating the orchitis. The dis-
ease is, as a rule, unilateral, and oc-
curs usually between the eighth and
sixteenth day of the mumps. A chill
at the onset is not uncommon, and
more or less fever is an accompani-
ment. The acute symptoms increase
somewhat slowly during a period of
three to six davs, when thev subside
and the swelling rapidly diminishes.
So rapid, in fact, is the return to nor-
mal conditions that it is clear that
the inflammation does not go beyond
the stage of serous exudation. In bi-
lateral orchitis one side precedes the
other, as a rule, by one or two days.
In many cases, as the orchitis de-
velops the parotitis subsides, which
has given rise to the theory of me-
tastasis.
The writer has had 7 cases of par-
tial or complete (so complete that not
a vestige of prostatic tissue could be
made out) atrophy of the prostate,
in which an antecedent parotiditis
seemed to j^e the sole etiological fac-
tor; in some of these cases (5) the
atrophy was accompanied by atrophy
of the testicles; in 2 the testicles
seemed to be unaffected. W. J. Rob-
inson (Letter to the N. Y. Med. Jour.,
Mar. 6, 1915).
In a series of 115 cases, epididy-
mitis was met by the writer in 20 in-
stances, in 18 of which it was inde-
pendent of orchitis. It began about
the sixth day of the disease and lasted
fifteen to twenty days. In half the
cases it was accompanied by distinct
swelling of the organ, which in the
remaining instances was merely ten-
SALIVARY GLANDS, DISEASES OF (CRANDALL AND MILLS). 67
der. Inflammation of the vas defer- male patients developed orchitis and
ens was noted in 40 cases, generally 5.3 per cent, of the women had mas-
independently of epididymitis or or- titis; that is, about half of the women
chitis. It began on the second or who were nursing infants at the time.
third day of the disease, and was bi- Bertelsen (Ugeskrift for Laeger, Dec.
. lateral in 26 cases. Twenty-three 9, 1915).
cases showed prostatitis. Enlarge- ^^ ^„*._„„^ n r j-
r , , , , re ' Treatment. — Cases of ordinary
ment of the lymph-nodes of Scarpa s . ■'
triangle was met with in 10 cases, and seventy require but little medication,
of those of the iliac chain in 6 cases. A mild antiseptic mouth-wash should
Swelling of the tonsils took place in be given with a view of preventing
40 cases. Diarrhea was noted for two infection by pyogenic bacteria. The
or three days in 60 cases. In 2 cases ^.^^ ^^^^^^j^ ^^^ j. j^ ^^^^ ^^^ ^^^^^
appendicitis suddenly developed on , , , , • , , -r i • r
the tenth day; recovery in two weeks should be kept in bed if there IS fever,
took place in both instances under Warm camphorated oil is the most
rest, dieting, and local application of soothing application that can be used
ice. Ramond and Goubert (Presse locally.
med., Mar. 25, 1915). ^N\,^x^ there is considerable tension
In females inflammation of the or throbbing, the ice-bag sometimes
breast or ovaries occurs in very rare gives more relief than warm appli-
instances. The number of well- cations. In general terms, the treat-
authenticated cases of this complica- ment is the same as for other febrile
tion, it must be said, is very small, conditions.
Involvement of the thyroid gland and Buccal antisepsis, according to
of the lymphatic nodes has been Martin, diminishes the chances of
observed testicular complications in parotitis.
_,'.,, . , A 4 per cent, solution of boric acid
Prognosis.-Mumps is rarely a ^^^^^ ^^^^^ ^^^^^^^ ^^ ^^.bolic acid
serious disease. It usually runs an should be employed as a gargle, and
uneventful course, and under 12 pilocarpine subcutaneously in doses
years complications are rare. In of % grain (0.01 Gm.) once daily, to
children of the so-called scrofulous diminish the pain and lower the tem-
1 ^. . . . perature in cases of orchitis,
type resolution is sometimes slow ^ ^, . ,, .
■' ^ The following ointment is recom-
and imperfect. Among 24,635 cases mended by Tranchet:—
occurring in the army during the ^ idithyol,
Civil War there were 39 deaths: a iodide of lead, of
mortality so high as to lead to each 45 gr. (3 Gm.).
doubt regarding the accuracy of the Chloride of Ammo-
statistics. "*'«"* ^^ s^- (2 Gm.).
„ . , . . . Lard 1 oz. (31 Gm.).
tpidemic parotitis was never en-
countered in Greenland until the in- This ointment is to be applied to
fection was brought in 1913 by a ship the swelled parts three times a day.
from Denmark, and of the 2425 in- In some instances vaselin may be
dividuals in the district, about 1500 used in place of the lard, and some-
contracted the disease. In the times belladonna may be added with
writer's special district, 191 of the advantage.
285 individuals were affected, that is, Where fever and severe pain are
66 per cent, of the men and 68 per present, sodium salicylate is effective,
cent, oi the women. No infant under It should be combined with an
2 was affected; 18 per cent, of the alkali: —
68
SALIVARY GLANDS. DISEASES OF (CRANDALL AXD MILLS).
R Sadii salicylat.,
Sodii bicarb aa gr. v (0.3 Gm.).
Bcnzosnlphinid q. s.
Aqua q. s. ad fjss (15 c.c).
Sig. : Ever}' two or four hours.
Stark (Practitioner, Mar., 1911).
The application every morning of
pure tincture of iodine to the pharyn.x
and buccal mucous membrane, with
special attention to the gingival fold
and opening of Steno's duct, is recom-
mended as a prophylactic by the
writer from experience in military
barracks. A tablet of potassium
chlorate should also be kept con-
stantly in the mouth. Petrilli (Poli-
clinico, June 1, 1913).
The writer tried convalescent
serum in several cases, using 5 c.c.
for both subcutaneous and intraven-
ous injections. Very little reaction,
lessening of pain, and earlier sub-
sidence of swelling and of tempera-
ture were noted. Gradwohl (U. S.
Naval Med. Bull., Oct., 1919).
2. Metastatic or Symptomatic Par-
otitis.— This is an inflammation of the
parotid gland occurring as a result of
septic infection through the blood or
through the buccal secretions, in the
course of various affections, and often
ending in ulceration. It may be
acute or chronic. It is oftenest met
with in typhoid, typhus, and scarlet
fevers, cholera, dysentery, plague,
pyemia, pneumonia, influenza, puer-
peral fever, erysipelas, and other in-
fectious disorders. It may result,
also, from poisoning by mercury,
lead, and the iodides. Inflammation
of the testicles is another cause, espe-
cially when the process is gonorrheal.
Injuries of the alimentary canal and
of the testicle or pelvic organs may
also give rise to it. Parotitis may
follow abdominal operations, espe-
cially ovariotomy, hysterectomy, and
laparotomy for peritonitis. It has
also been observed in cases of neu-
ritis, facial paralysis, and diabetes.
Symptoms. — When acute the gland
rapidly swells. The tem])erature
rises to 103° or 104° F. (39.4° or
40° C). The whole face becomes
enlarged, when both glands are in-
volved, and the lids edematous. The
pain is sometimes very severe, owing
to the tense capsule with which the
gland is surrounded. Pus-formation
promptly follows in the majority of
cases, and the pus may burrow in
various directions, — the auditory me-
atus, the thoracic cellular tissue, the
retropharyngeal tissues, the maxillary
joints, etc., — and cause serious lesions
if not promptly evacuated by incision.
Parotitis was encountered by the
writer in 16 of the 760 cases of ty-
phoid fever in his service. Several
of the men died. The typhoid was
always unusually severe in these
parotitis cases. Cahanescu (Wiener
klin. Woch., May 27, 1915).
Case of suppurative parotiditis fol-
lowing pneumonia in a boy of 3 years.
Five days later the temperature,
which had been in the neighborhood
of 99.5° F. (37.5° C). reached 104° F.
(40° C). No signs in the chest were
demonstrable, but on the following
day a hard, tender swelling appeared
in the right parotid region. Three
days later a deep incision below the
right ear reached an abscess and a
small amount of pus was removed.
The smear showed pneumococci and
a few staphylococci. The tempera-
ture fell and the recovery was un-
eventful. J. P. Parkinson (Brit. Jour,
of Children's Dis., May, 1915).
In the chronic form — which may
result from mumps, neighboring in-
flammatory processes, syphilis, the
excessive use of mercury, etc. — the
gland is also enlarged, but less pain-
ful, and may remain so several years.
Pathology. — The process is a sup-
purative one. The pus may dis-
charge through the cheek or through
SALOPHEN.
69
the external auditory meatus, and
more rarely into the mouth, esopha-
gus, or anterior mediastinum. The
abscess may be confined to the paro-
tid g-land and its immediate surround-
ing- tissues or it may be so large as
to involve the muscles and other soft
tissues, and even the periosteum of
the bones. The middle ear is not in-
frequently involved, as well as the
central meninges. Thrombosis of
the jugular and other veins some-
times leads to septicemia. In rare
instances the process terminates in
gangrene.
Prognosis. — The result depends
largely upon the condition of the pa-
tient at the time of the onset of the
parotitis. If much reduced by the
primary disease, the complication
often precipitates a fatal result. If
it occurs during convalescence and
the patient is not already reduced, a
favorable result may be expected. In
other words, suppurative parotitis in
itself is not usually fatal. Induration
and enlargement of the glands is a
common result.
Treatment. — By introducing a probe
into Stenson's duct at the first ap-
pearance of swelling, and making
pressure from the outside, a small
quantity of pus may sometimes be
evacuated and general suppuration
.prevented. If this fails, poultices
should be applied to hasten suppu-
ration. An incision should be made,
with antiseptic precautions, as soon
as fluctuation can be detected. The
treatment throughout should be that
appropriate for any acute abscess.
Floyd M. Crandall,
New York,
AND
H. Brooker Mills,
Philadelphia.
SALOL. See Salicylic Acid.
SALOPHEN.-Salophen (acetyl-
paramido-phenol salicylate) contains 50.9
per cent, salicylic acid. It occurs in fine,
white, odorless and tasteless scales; solu-
ble in alcohol, ether, alkalies, and hot
water, and nearly insoluble in cold water.
It is not official.
Salophen was introduced as a substi-
tute for salicylic acid and salol by P.
Guttmann (Berl. klin. Woch., No. 52,
'91). It is said to be less poisonous than
salol or salicylic acid, because the phenol
of the latter remedies is replaced by an
innocuous compound of phenol.
DOSE AND PHYSIOLOGICAL AC-
TION.—Salophen, like salol, seems to
suffer no action until it reaches the in-
testines, when the pancreatic juice splits
it up into its component parts, salicylic
acid and acetyl-paramido-phenol. As the
latter appears innocuous, the further ac-
tion of salophen is that of its contained
salicylic acid. It has, however, certain
advantages over the latter in that it is
unirritating and tasteless and is not de-
pressing. It may be given for consider-
able periods of time without causing
nausea, anorexia, tinnitus, or other un-
pleasant symptoms. It possesses antisep-
tic, antipyretic, and analgesic properties,
and is given in doses of from 5 to 15
grains (0.3 to 1 Gm.). The maximum single
dose is given as 20 grains (1.3 Gm.); not
more than 90 grains (6 Gm.) should be
given during the twenty-four hours.
THERAPEUTICS. — The therapeutics
of this remedy are the same as those
of salol and salicylic acid. It is given in
the same cases, and in similar doses, and
is generally to be preferred to either of
them, for the reasons given above. It is
well suited, also, for use in diseases of
children.
Salophen has a most favorable influ-
ence upon psoriasis, used in 10 per cent,
ointment.
Salophen exerts an incontestable action
upon acute and subacute rheumatism,
but its effects are less constant than those
of salicylic acid or sodium salicylate.
In chronic and blennorrhagic rheumatism
it has not shown itself superior to other
drugs.
70
SANDALWOOD AND OIL OF SANDALWOOD.
SANGUINARIA.
In chronic articular rheumatism it is
no more useful than the above-mentioned
drugs. It is an excellent antineuralgic
and analgesic in cephalalgia, migraine,
odontalgia; facial, trifacial, and intercos-
tal neuralgia; am! in the nervous form
of influenza. It produces good results in
chorea. It acts well in various skin af-
fections which are accompanied with itch-
ing: prurigo, urticaria, pruritus of dia-
betes, eczema, and psoriasis.
SALPINGITIS. See Ovaries and
Fallopian Tubes, Diseases of.
SALT. See Sodium.
SALVARSAN See Dioxydiami-
DOARSENOBENZOL.
SANDALWOOD AND OIL
OF SANDALWOOD. -Sandalwood
(red saunders; santaluni rubrum, U. S. P.)
is the wood of Pterocarpiis santalinns (nat.
ord., Leguminosse). It occurs in the form
of raspings, chips, or splinters. It con-
tains a red coloring matter of a resinous
character, known as santalic acid, or san-
talin, which occurs in fine red, odorless,
and tasteless needles; soluble in alcohol,
ether, in concentrated sulphuric acid, and
in alkalies, but insoluble in water. It is
used in pharmacy for imparting a red
color to alcoholic solutions and tinctures.
It is the coloring principle of the com-
pound spirit for tincture) of lavender. It
has no medicinal properties.
Oil of sandalwood (oil of santal; oleum
santali, U. S. P.) is a volatile oil distilled
from the wood of Santaluni aWuin (nat.
ord., Santalaceje), indigenous to India.
East Indian sandalwood oil is a rather
viscid, yellowish, or pale-straw liquid, hav-
ing ah unpleasant, resinous, harsh taste,
and a faint but persistent aromatic odor.
The chief constituent is an alcohol known
as santalol.
PHYSIOLOGICAL ACTION AND
DOSE. — Oil of sandalwood is a stimulant
in small doses, and an irritant in large
doses, to the various mucous membranes.
It checks the secretions of the mucous
membranes and causes dryness of the
throat and thirst. S. Rosenberg has
noticed, after doses of 60 drops a day,
irritation of the alimentary canal, burning
in the urethra during micturition, and an
eruption of small red prominences upon
the entire surface of the body, involving
even the conjunctiva;. Large doses may
produce considerable lumbar pain.
Its general systemic action is unknown.
It is apparently more stimulating than oil
of eucalyptus, and rather less than tere-
l)ene. It is eliminated l)y the urinary and
respiratory mucous membranes; the odor
is sometimes perceptible in the perspira-
tion. Unlike copaiba, it causes no cuta-
neous eruptions, and is less likely to pro-
duce gastric or intestinal disturbance.
Absorption and elimination are very
rapid; it may be detected by its odor in
the urine half an hour after its ingestion.
It may be given in doses of from 5 to 30
minims (0.3 to 2 c.c), in capsules or dis-
solved in alcohol and flavored with cin-
namon, in emulsion, or on sugar.
THERAPEUTICS.— Oil of sandalwood
is an efficient remedy in asthma, chronic
bronchitis, in the later stage of acute bron-
chitis, and in the subacute or chronic stage
of gonorrhea. It is also used as an in-
gredient of perfumes. It has also been
used in cystitis, but care should be taken
to avoid large doses, and thereby the
urethral scalding pain they cause.
SANGUINARIA. -Sanguinaria, or
blood-root, is the rhizome of Sanguinaria
canadensis (fani., Papaveracese), a native of
eastern and central North America. San-
guinaria contains citric and malic acids,
red resin, and starch, but its important
constituents are its alkaloids, at least
five in number, of which sanguinarine
and chclerythrine are the most important.
PREPARATIONS AND DOSES.—
Sanguinaria, U. S. P. (sanguinaria, or
blood-root). Dose, 1 to 5 grains (0.06 to
0.30 Gm.).
Tinctiira sanguinaria, U. S. P. (tincture
of sanguinaria). Dose, 10 to 40 minims
(0.60 to 2.60 c.c).
Sanguinarine (alkaloid). Dose, Yxn to
y^ grain (0.004 to 0.008 Gm.).
Fluidextractum sanguinarise, N. F. (fluid-
extract of sanguinaria). Dose, 1 to 5
minims (0.06 to 0.30 c.c).
Syrupus sanguinaria?, N. F. (syrup of
sanguinaria). Dose, 30 minims (2 c.c),
representing 6 grains (0.4 Gm.) of san-
guinaria.
SANTONICA AND SANTONIN.
71
Syrupus pini strobi comp., N. F. (com-
pound syrup of white pine). Dose, 2
fluidrams (8 c.c), representing 5 grains
(0.3 Gm.) each of white-pine bark and
wild-cherry bark, together with small
quantities of aralia, populus, sanguinaria,
sassafras, cudbear, glycerin, alcohol, and
a little chloroform.
PHYSIOLOGICAL ACTION.— The
powder inhaled causes violent sneezing
and free secretion of mucus. It is feebly
escharotic. The taste is harsh and bitter.
In small doses sanguinaria produces a
sense of warmth in the stomach and stim-
ulates the secretions. Moderate doses
produce nausea and depression of the cir-
culation. In large doses it causes inflam-
mation of the stomach with intense burn-
ing, thirst, vomiting, dimness of vision,
dilatation of the pupils, vertigo, great pros-
tration and muscular relaxation, cold and
clammy skin, and collapse. After a pre-
liminary increase of arterial tension the
heart action becomes depressed. The
spinal reflexes are reduced and the spinal
centers paralyzed. Death is often pre-
ceded by convulsions either of spinal
origin or from carbonic acid poisoning
due to failure of respiration.
TREATMENT OF POISONING.—
The stomach and bowels should be
washed out with warm water. The dif-
fusible stimulants should be administered.
Digitalis, amyl nitrite and strychnine
hypodermically are efficient, with mor-
phine and atropine, if necessary, to relieve
pain or severe nausea. The patient should
be kept warm.
THERAPEUTIC ACTION. — Sangui-
naria is chiefly used as a stimulating
expectorant in subacute and chronic
bronchitis.
SANTONICA AND SAN-
XONIN. — Santonica (Levant or German
wormseed) is the unexpanded flower-
heads of Artemisia pauciflora (fam., Com-
positse), a native of Turkestan and the
surrounding countries. It contains about
1 per cent, of volatile oil, IK' to 3 per
cent, of santonin and a variable amount
of artemisin. Since the isolation of san-
tonin from santonica, the use of the crude
drug has been abandoned.
Santonin occurs in faintly acid, shining,
colorless, flattened, rhombic prismatic
crystals, odorless, and at first nearly
tasteless, but with a bitter after-taste. It
is permanent in the air, but turns yel-
low on exposure to light. It is soluble
in alkalies and most volatile oils, in 5300
parts of cold water, 250 parts of boiling
water, 34 parts of alcohol, 78 parts of
ether, and in 2.5 parts of chloroform, and
nearly insoluble in glycerin. Colored
santonin is an unreliable remedy.
PREPARATIONS AND DOSES.—
Santoiiinuui, U. S. P. (santonin). Dose,
1 to 4 grains (0.06 to 0.25 Gm.) for an
adult, ^ to K grain (0.015 to 0.03 Gm.)
for a child.
Santonica, U. S. P. VIII (santonica).
Dose, 10 to 40 grains (0.60 to 2.60 Gm.).
Trochisci santonini, N. F. (troches of
santonin, worm lozenges), each contain-
ing K grain (0.03 Gm.) santonin. Dose, 1
to 4 troches.
Trochisci santonini compositi, N. F., con-
taining santonin and calomel, of each, Yz
grain (0.03 Gm.).
Sodium santoninate, official in the U. S.
Pharmacopoeia of 1880, is a very soluble
salt, a fact which forbids its use and that
of other santoninates, since the object of
using this remedy is to act locally upon
the parasites. When given for other pur-
poses than as a vermifuge the dose is 5
to 10 grains (0.30 to 0.65 Gm.).
PHYSIOLOGICAL ACTION. — San-
tonin is decomposed in the blood, disturb-
ing the nutrition of the cerebral centers,
and producing xanthopsia or chromatopsia,
a condition where objects appear yellow,
red, green, or blue, either by staining the
humors of the eye or by its action upon
the retina and perceptive centers; the
urine is stained a greenish-yellow, or, if
alkaline, a reddish-purple color, due to
xanthopsin, a derivative of santonin.
Elimination is by the kidneys, is slow,
taking about two days for the removal
of an ordinary dose. There is an in-
creased flow of urine and more frequent
micturition.
POISONING BY SANTONIN.— This
often occurs l)y children eating freely of
worm lozenges, or from susceptibility to
its action. Toxic doses produce alarm-
ing symptoms — muscular tremors, vertigo,
cold sweats, mydriasis, stupor and epi-
72
SARSAPARILLA.
leptiform convulsions. Death occurs from
respiratory failure. A case of urticaria
occurred after a 3-grain dose to a child,
and a general niorbilloid eruption and in-
tense punctiform rash on the buccal and
faucial mucous membranes after a 5-grain
dose taken by an adult.
Treatment of Santonin Poisoning. — The
treatnu-nt consists of the use of diffusible
stimulants, hot baths, demulcent drinks,
belladonna and strychnine, with inhala-
tions of ether to control the convulsions.
THERAPEUTIC USES.— The most
important use of santonin is that of a
vermifuge to expel the roundworm {As-
caris lumbricoidcs or the Oxyiiris vcr~
micuJaris (thread- or seat- worm) from
the intestines. It has no efifect upon the
tapeworm. In persistent incontinence of
urine santonin has been efficient when all
other remedies have failed. It is often
useful when the optic nerve is diseased,
to restore the activity of vision, and in
some cases of color blindness.
As an anthelmintic santonin should be
administered on an empty stomach.
Whitla and Demme combine santonin with
castor oil, but in aggravated cases the lat-
ter preferred to give it in a slightly
sweetened oleaginous solution, ^ grain
(0.03 Gm.) to 1 ounce (30 c.c.) of olive
oil. A previous saline purgative (mag-
nesia or rhubarb and magnesia) removes
the mucus in which worms breed. The
dose of santonin, given at night, should be
followed by a saline purgative in the
morning, preferably before breakfast.
Santonin has been recommended by
Whitehead, of Manchester, in amenor-
rhea, especially when due to chloranemia.
He gives a 10-grain (0.6 Gm.) dose on
two successive nights. Cadogan Master-
man has found this method useful in
severe uterine colic arising from suppres-
sion of the menses.
SAPREMIA. See Wounds, Septic.
SARCOMA. See Cancer.
SARSAPARILLA.— Sarsaparilla is
the dried root of Smilax vicdica, Sinilax
ornata, Smilax papyracccc, Smilax officinalis
(fam., Liliacese), and other varieties of
smilax indigenous to central America,
Mexico, Brazil, Honduras, and other trop-
ical and subtropical American countries.
The roots are without odor and have a
mucilaginous, bitter and acrid taste. Sar-
saparilla contains about 3 per cent, of
saponin-like substance (separable into 3
glucosides), up to 15 per cent, of starch,
a little resin, volatile oil, pectin, calcium
oxalate, etc. The glucosides are the im-
portant constituents, sarsasaponin, paril-
lin, and smilasaponin, the last two being
known as smilaciii.
PREPARATIONS AND DOSES.—
Sarsaparilla, U. S. P. (sarsaparilla root).
Fluidextractum sarsaparilla, U. S. P.
(fluidextract of sarsaparilla). Dose, J/2 to
1 dram (2 to 4 c.c).
Fluidextractum sarsaparillcc compositum,
U. S. P. (compound fluidextract of sarsa-
parilla), containing sarsaparilla, 15 parts;
licorice, 12 parts; sassafras bark, 10 parts;
mezereum, 3 parts; glycerin, 10 parts;
and diluted alcohol to make 100 parts.
Dose, ^ to 1 dram (2 to 4 c.c).
Syrupus sarsaparillce compositus, U. S. P.
(compound syrup of sarsaparilla), con-
taining fluidextract of sarsaparilla (20
per cent.), fluidextracts of licorice and
senna (of each 1.5 per cent.), and oils
of anise, gaultheria, and sassafras (of each
0.02 per cent.). Dose, 1 to 4 drams
(4 to 16 c.c).
THERAPEUTIC USES.— Sarsaparilla
is probably inert, or nearly so, in the
dose usually given, though moderate doses
apparently aid digestion and improve the
appetite. Its chief value is as a pleasant
vehicle for disguising the taste of the
iodides and of the mercurial salts. While
there is no evidence of a curative action
of sarsaparilla by itself in syphilis, a tem-
porary recourse to the remedy has been
considered useful, especially in debilitated
patients in whom mercury and the
iodides have seemingly lost their bene-
ficial action or have been improperly ad-
ministered. Phillips recommends this
remedy in chronic lung affections with
much wasting; in chronic rheumatism
and cutaneous disorders with venereal
taint. Sir Astley Cooper advises its use
in the cachexia caused by chronic sup-
puration, in chronic abscesses, ulcers, and
bone disease. Zittmann's decoction (a de-
coction of sarsaparilla, calomel, cinnabar,
alum, senna, licorice, anise-seed and fen-
SCABIES.
73
nel) is much used by the German
physicians in chronic rheumatism, syphiUs,
and scrofula. In domestic medicine sar-
saparilla has been a favorite blood
purifier.
SCABIES.— DEFINITION.— An in-
flammatory contagious disease of the
skin, due to the presence of the Acarus
scabici and attended by severe pruritus.
SYMPTOMS.— The eruption produced
by the Acarus scabici consists of scattered
vesicles and papules, which are usually
located between the fingers and on the
flexor side of the wrists and elbows.
The axillae, mons veneris, abdomen and
buttocks, the penis, the mammse, and in
children the legs and feet are the points
of predilection next in order. The bur-
rows of the parasite resemble scratches,
which, upon close examination, may be
seen to be beaded. The Acarus may
readily be extracted from its burrow with
the tip of a needle for microscopic ex-
amination. The eruption is attended by
severe itching, which is especially marked
at night. The scratching to which the
patient subjects the part greatly increases
the local irritation. The eruption may
become pustular or complicated by other
dermatoses (eczema, urticaria, etc.), and
present various characteristics due to the
accumulation of epidermic detritus, dead
acari, etc., or accumulated crusts. The
hairs of the limbs afifected are often shed,
and the nails may become hypertrophied.
Schamberg and Strickler found that of
forty-seven cases of scabies, over 80 per
cent, showed 5 or more per cent, of
eosinophiles; the maximum was 19 per
cent., and the average 7 per cent, (the
normal maximum is 4 per cent.). The
incubation period extends from two days
to a week. Occasionally the itching is
absent — apruriginous scabies. During a
general illness scabies is apt to disappear
or improve; but the disease reappears as
soon as convalescence is established.
ETIOLOGY.— The Acarus scabici is about
one-quarter millimeter long, and resem-
bles an eight-footed turtle in general out-
line; the males live under the skin or epi-
dermic scales, the females under the
epidermis in the burrows, where they de-
posit their eggs. Acarus does not inhabit
the prickly layer, but the undermost part
of the middle layer of the epidermis. The
eczema of scabies is not caused by
scratching, but by irritating substances
given off by the Acarus, according to
Torok.
While the female mite is visible to the
naked eye, the male is much smaller.
Females are more numerous than males,
and when fecundated penetrate into the
epiderm, making a burrow in which they
deposit their ova, from 6 or 9 up to 30 in
number. The mite cannot retreat be-
cause of several bristling hairs project-
ing from her body; she dies in the bur-
row; the eggs mature in a few days, and
the resulting larval forms emerge upon
the surface and become sexually active,
become impregnated, burrow, deposit ova
and die, and thus the cycle continues.
The life of the individual mite is from two
to three months. The males live on the
surface near the burrows. The disease is
very contagious, through contact with af-
fected individuals and any wearing apparel
or bedclothing that they may have used.
TREATMENT.— Scabies may be rap-
idly cured by adopting Hardy's method;
scrubbing with soap and water, using a
brush twenty minutes; the same pro-
cedure thirty minutes, but with the part
immersed in the soap-water; rubbing of
the part with the Helmerich-Hardy oint-
ment: Carbonate of potash, 25 grains
(1.62 Gm.); sulphur, 50 grains (3.25 Gm.);
lard, 5 drams (20 Gm.). — M. This is
left on two hours and the parts are bathed
as before, but not brushed. Pruritus
may usually be relieved by means of a
2 per cent, menthol ointment. Petrolatum
is sometimes sufficient.
The simple sulphur ointment thor-
oughly, though gently, rubbed in at night
before retiring, followed the next morn-
ing by a warm bath, is often sufficient
to cure scabies when persisted in for two
or three weeks, but the underwear should
be very frequently changed and boiled for
half an hour or baked in an oven at
120° C. In many cases the ordinary sul-
phur ointment is too strong; it is always
best to reduce its strength by mixing
it with an equal quantity of benzoated
lard. Sulphur baths are also valuable,
but ointments can be kept in contact
74
SCAMMONY.
longer with diseased parts, and are there-
fore more destructive to the parasite.
Julien recommends painting the entire
body with balsam of Peru, 3 parts, and
glycerin, 1 part, which exercises a toxic
action on the Acarus. No soap and water
should be used before its application.
With a l)rush a thin layer of the balsam
is laid on at night, followed by gentle
rubbing. A bath is taken on the fol-
lowing morning. The remedy causes no
irritation, as a rule.
For scabies in infants and young chil-
dren, Hartzcll recommends equal parts of
styrax and olive oil, or 1 or 2 drams (4 to
8 Gm.) of balsam of Peru to 1 ounce (30
Gm.) of vaseline.
Betanaphthol (20 per cent, ointment),
styrax, creolin (10 per cent, ointment),
petroleum, and Hebra's modification of
Wilkinson's ointment (unguentum sul-
phuris comp., N. F., which contains pre-
cipitated chalk, 10; sublimed sulphur, 15;
oil of cade, 15; soft soap, 30; lard, 30
parts) have been used with success.
Scabies has been successfully treated
with nicotine soap. It is of a dark-brown
color, and may be scented with oil of
bergamot. It consists of tobacco extract,
5 per cent.; precipitated sulphur, 5 per
cent.; and ovei-fatty soap, 90 per cent.
After thorough bathing the body and
limbs may be rubbed lightly with washed!
sulphur, less than ^ teaspoonful for each
person; this to be followed by clean
underclothes and clean sheets with yi
dram (2 Gm.) of sulphur dusted between
them. If this is repeated every second or
third day the cure, in ordinary cases, is
complete in a week.
For the treatment of secondary pustular
complications Knowles, 1918, recommends
ammoniated mercury ointment, 20 to 40
grains (1.3 to 2.6 Gm.) to the ounce (30
Gm.). Incipient boils can be cured by
daily rubbing for ten minutes with 25 per
cent, ichthyol ointment. If they are re-
current, an autogenous vaccine should be
used. Septic ulceration or cellulitis may
require rest in bed, and should be treated
by the local application of ammoniated!
mercury in zinc oxide ointment.
Another plan is to change the parasiti-
cide during the treatment (Montgomery).
Use a sulphur-balsam Peru ointment for
three days, a betanaphthol ointment for
three days, and a creolin ointment for
the remaining time.
SCALP. See Head and Brain,
Diseases and Injuries of.
SCAMMONY.— Scammony is the
gum resin from Convolvulus scamnionia
(fam., Convolvulaceae), derived from the
living roots of the plant. Its chief con-
stituent (80 to 95 per cent.) is a gluco-
sidal resin called scammonium.
PREPARATIONS AND DOSES.—
Scammonke radix, U. S. P. (scammony).
Dose, 4 to 8 grains (0.25 to 0.5 Gm.).
Rcshia scammonke, U. S. P. (resin of
scammony). Dose, 3 to 5 grains (0.2
to 0.3 Gm.).
Extractum colocynthidis compositiim, U. S.
P. (compound extract of colocynth, con-
taining 14 per cent, of resin of scam-
mony). Dose, 5 to 10 grains (0.30 to
0.60 Gm.).
Pilida catharticce compositcc, U. S. P. (com-
pound cathartic pills containing 1% grains
(0.08 Gm.) of compound extract of colo-
cynth in each pill). Dose 2 pills.
Pilulce catliarticie vegetahiles, N. F. (vege-
table cathartic pills containing 1 grain —
0.06 Gm. — of compound extract of colo-
cynth in each pill). Dose 2 pills.
It is also an ingredient of pilula colo-
cynthidis comp. (pil. cocciae), N. F., of
pilul^e colocynthidis et hyoscyami, N. F.,
and of pilula colocynthidis et podophylli,
N. F.
PHYSIOLOGICAL ACTION.— Scam-
mony is a drastic hydragogue and feebly
cholagogue purgative. When given alone
it causes considerable griping. It is un-
certain in action by reason of its frequent
adulteration and its insolubility in the
gastrointestinal juices if they are acid.
Gastritis and enteritis, if present, contra-
indicate its use. Given in large doses it
may cause severe gastroenteritis and
fatal purgation. It should not be given
alone, but combined with other cathartics
and aromatics, to modify its harsh action.
Its effects are usually manifested within
four hours.
THERAPEUTIC USES.— On account
of its tastelessness it is a favorite pur-
gative in children, combined with calomel
SCARLET FEVER (CRANDALL AND MILLS).
75
and triturated with sugar of milk. It is
useful in cerebral affections and dropsies,
in the form of compound extract of
colocynth. It is useful to clear the
intestines of mucus and as an anthel-
mintic against both roundworms and
tapeworms. It is a purgative well adapted
to cases of obstinate constipation and
impaction of feces and in cases of mania
and hypochondriasis. W.
SCARLET FEVER. —Scarlatina.
DEFINITION.— Scarlet fever is
an acute, infectious, contagious, erup-
tive, disease presenting-, in typical
cases, the following features : After
a period of incubation of from two to
four days there is a sudden onset of
sore throat, vomiting, and fever;
within twenty-four hours a character-
istic eruption appears and continues
for about six days, when it terminates
in desquamation.
While the average period of incu-
bation of scarlet fever (i.e., the period
between exposure and the appearance
of symptoms) has been stated to be
from two to four days, with a maxi-
mum of seven, the latest observations
show that this period is very vari-
able. The limits of the period of
incubation are practically from four
to twenty days, with an average of
ten to fourteen days. J. W. Scheres-
chewsky (Public Health Reports,
Nov. 27, 1914).
SYMPTOMS.— From the attack so
mild that diagnosis is difficult to the
fiercely malignant form we see every
possible degree of severity. Notwith-
standing this variability of type, the
majority of cases pursue a fairly
uniform course, and may, with pro-
priety, be called ordinary cases.
Other types may be described as mild,
severe, and malignant.
Ordinary Type. — The invasion is
usually sudden, and is marked by
vomiting, fever sore throat, and rapid
pulse. Occasionally a short period of
malaise precedes the onset of definite
symptoms. In older children a chill
is sometimes the first symptom; in
younger children a convulsion. The
vomiting is usually repeated several
times, and is not accompanied by
nausea. When it occurs late in the
disease it is a far more unfavorable
symptom than at the outset. The
intensity of the period of invasion is
usually indicative of the severity of
the attack, though this is a rule sub-
ject to many exceptions.
The temperature is frequently
found to be 103° F. (39.4° C.) at the
first visit and may reach 104° or 105°
F. (40° or 40.5° C.) on the first day.
A temperature on the first day above
104>^° F. (40.2° C.) indicates a severe
attack; below 102° F. (38.9° C.) a
mild attack. The highest point is
commonly reached at the height of
the eruption. It then begins to sub-
side and becomes normal at a varying
period, ranging from the ninth to the
fifteenth day. The fever is frequently
remittent and in mild cases almost
intermittent in character. There is
no typical temperature range. The
febrile stage, even in quite severe
cases, may be limited to six or seven
days, or it may be prolonged to four-
teen or fifteen days without obvious
cause.
Any extensive rise or fall from the
level maintained during the fastigium,
or a rise interrupting the progressive
lytical resolution indicates an inter-
current or complicating condition
and not an essential part of the scar-
latina pyrexia. Lysis in scarlatina
begins on the fifth or sixth day, so
that if a febrile case shows the be-
ginning of lysis on the second day
thereafter, we know that the case was
four days old on admission. The
existence of a complication is re-
76
SCARLET FEVER (CRANDALL AND MILLS).
vealcd by a sudden rise during the
lytical stage, the character of the
complication being often shown by
the temperature curve, and the
changes in the pulse and respiration
rate. A somewhat septic curve with
increase in pulse and respiration sug-
gests bronchopneumonia; a cardiac
complication may be suspected from
a suspension of the lytical tempera-
ture curve with greatly increased
pulse rate and a moderate increase in
respiration; a meningitis or menin-
gismus attending an otitis media or
mastoiditis is frequently indicated
through an interruption of the stage
of lysis by an increase of fever of
septic character coupled with a lower
pulse rate than is usual at the height
of the fever, although it might also
indicate the presence of an acute glo-
merular nephritis. Nephritis is not
as frequent in hospital cases as in
private practice for two reasons: The
patient is kept strictly in bed until
desquamation is almost complete and
is kept on a fluid diet until he has
well passed the stage of acute symp-
toms. H. W. Berg (Med. Record,
May 11, 1912).
In a study of 17 cases of uncom-
plicated scarlet fever and of 2 cases
of scarlet fever with nephritis, the
writers found that examination of the
urine for albumin is of more value
than the functional tests for the de-
tection of the onset of kidney com-
plication. Veeder and Johnston
(Amer. Jour, of Dis. of Children,
Mar., 1920).
A pulse abnormally rapid as com-
pared with the height of the tempera-
ture is quite characteristic of scarlet
fever. It is often 150 on the first day,
and continues rapid throughout the
disease.
One of the earliest symptoms is
sore throat. The fauces, tonsils, and
pharynx are of a imiform bright-red
color, and on the hard palate numer-
ous dark-red macules may be seen.
In mild cases the throat symptoms
may be very slight; in more severe
cases the tonsils may be studded with
follicular spots, or smeared over with
a tenacious exudate closely resem-
bling a pseudomembrane. There is
frequently a discharge from the nose,
which may consist of clear, tenacious
mucus or mucopus. The glands at
the angle of the jaw frequently be-
come enlarged. Gregor of Petrograd
has recently reported observations
upon the thyroid and believes that
there is a special form of scarlatinal
thyroiditis. It is possible that these
changes may have some bearing upon
the occurrence of thyroid disease in
later life. The spleen is not usually
enlarged.
Not one of the individual symp- '
toms can be depended upon to estab-
lish the diagnosis. Next to the
throat, the condition of the tongue
is the most reliable symptom, some
enlargement of the papillae of the tip
and border being usually observable,
although this symptom is much more
frequently missing than is the angina
and may occur in other conditions.
Miller (Arch, of Pediatrics, Apr.,
1912).
As the disease progresses, the
tongue, which is at first coated, often
assumes the so-called strawberry ap-
pearance.
Considerable confusion exists as
to what the strawberry tongue really
is. It is not a white tongue with red
papilL-e ; such a tongue is seen in vari-
ous conditions. The true strawberry
tongue was originally described by
Flint as follows : "The tongue in the
first days is usually coated. In the
progress of the disease the tongue
usually exfoliates, leaving the surface
clean and reddened and the papillae
enlarged. The appearance is strik-
ingly like that of a ripe strawberry.
Differential Diagnosis of Eruptions in Children's Diseases.
1. Scarlet fever. 5. Strawberry tongue of scarlet fever.
2. Scarlet fever ; desquamation. 6. Variola.
3. Rubeola. 7. Variola ; confluence.
4. Rubella. 8. Varicella.
9. Variola-like varicella.
SCARLET FEVER (CRANDALL AND MILLS).
17
The strawberry-like tongue is a
pathognomonic symptom ; it is pecul-
iar to this disease. It is often, but
not uniformly, present." The term
should be applied to the red, clean
tongue with prominent papillae which
follows a coated tongue.
The eruption usually appears with-
in twenty-four hours after the initial
vomiting. It is not infrequently seen
after twelve hours, and is sometimes
delayed for thirty-six hours and in
rare cases to the fourth or fifth day.
There is frequently intense itching
or burning of the skin. The rash is
usually well developed during the
second day of its appearance. It
then continues from four to six days,
when it gradually subsides. It usu-
ally appears first over the front of the
neck and upper part of the chest. It
consists of minute points of bright-
scarlet color closely grouped together
on a slightly reddened skin. They
become confluent in places, forming
bright-scarlet patches, but over the
most of the surface they remain dis-
crete throughout. Being hyperemic
in nature, the rash disappears on
pressure, leaving, for a perceptible
time, a white spot. An eruption of
very fine vesicles is seen in rare in-
stances, and occasionally a blotchy
eruption appears early on the face, but
subsides as the typical rash develops.
One of the most characteristic
symptoms of scarlet fever is the des-
quamation. It rarely begins before
the sixth day, and is frequently de-
layed until the second week. It ap-
pears first on the neck and between
the fingers. It begins as fine, branny
scales, but soon changes to large
lamellar scales. Sometimes the skin
can be peeled oflf in strips. It con-
tinues from ten to thirty days, and is
most persistent where the skin is
thickest. It frequently continues
about the fingers and nails after other
portions of the body are clear, which
explains the readiness with which the
disease is conveyed by letters. When
the skin has received careful atten-
tion, the desquamation is sometimes
almost imperceptible. In rare in-
stances a second desquamation occurs.
The urine becomes scanty and
high colored during the febrile stage,
and frequently contains a slight
amount of albumin and sometimes
blood and hyaline casts. Except in
the more severe forms, suppression is
rare and dropsy still rnore so. These
symptoms usually subside as the fever
falls. The kidney symptoms at this
stage rarely prove serious. They
may, however, do so, and always de-
mand attention. The more serious
kidney symptoms occur later and will
be considered as a complication.
Mild Type. — Scarlet fever is some-
times so mild as to render diagnosis
very difficult. The symptoms may be
so slight that medical aid is not
sought. As a rule, however, there is
an onset of vomiting, fever, and sore
throat, as in the ordinary type, but
none of the symptoms are urgent.
The vomiting is not persistent, the
temperature does not rise above 102""
or 103° F. (38.9° or 39.4° C), and the
throat presents only the symptoms of
mild pharyngitis. I have seen an un-
doubted case in which the tempera-
ture never rose to 101° F. (38.4° C).
It may become normal on the fourth
or sixth day. The eruption is often
very faint, and may not appear on the
face. It may, however, be bright and
distinctive for twenty-four hours and
then fade away so rapidly as to have
disappeared by the fifth day. In rare
78
SCARLET FEVER (CRANDALL AND MILLS).
instances it is an evanescent rash
which disappears entirely within
twenty-four hours. Nephritis may be
a sequel, due in many cases to ex-
posure and lack of care : the natural
results of so mild an illness. Owing
to this lack of care and isolation, the
patient may become very dangerous
to others. It is by these mild cases
that the disease is sometimes sown
broadcast. A mild attack in one child
may produce a malignant one in an-
other.
Severe Type. — Not only are the
symptoms of this type severe, but the
various stages are prolonged. The
fever may continue for three weeks or
more, and the stage of desquamation
for even a longer time. A fatal ter-
mination is common, death occurring
usually during the second week. The
chief peculiarity which distinguishes
this from the ordinary type is the
presence of septic symptoms due to
streptococcic infection. The type
might, therefore, with propriety be
called complicated type. The throat
is usually the first to show the evi-
dence of streptococcic invasion. On
the third day, and in some cases on
the first or second day, a membranous
exudate appears on the tonsils and
soon invades the pharynx and naso-
pharynx. A purulent nasal discharge
appears, and the lymphatic glands at
the angle of the jaw begin to swell,
the cellular tissues being so involved
as to often cause immense enlarge-
ment. The Eustachian tubes are in-
volved, and purulent otitis media fol-
lows ; but the lar3aix commonly
escapes.
In 10,000 cases recorded in ten
years, 2L06 per cent, had ear disease.
There are two forms of scarlatinal
otitis. The first is a comparatively
mild ordinary inflammation, and has
no rchuion to the scarlet fever except
that it occurs at the same time. It
is most frequent in cases with little
or no throat trouble. The second
type is the so-called scarlatino-diph-
theritic or necrotic otitis, and is
brought about by the same specific
cause as the scarlet fever itself. It
differs from the first type in being
very much more severe and involv-
ing extensive necrosis of the soft
parts and bones. P. Manasse
(Monats. f. Kinderheilk., July, 1913).
The urine contains albumin and
perhaps blood-cells and hyaline and
epithelial casts. Symptoms of gen-
eral septic infection rapidly super-
vene. There is low delirium or
stupor; the child refuses nourishment
and may die from exhaustion ; but
sudden death is not uncommon.
Others, after overcoming one com-
plication after another, slowly recover
after a tedious convalescence.
Malignant Type. — Though very
rare, malignant scarlet fever does
sometimes occur. It begins with
convulsions and hyperpyrexia. The
scarlatinal poisoning may be so in-
tense as to cause death within twenty-
four hours. More commonly, death
does not occur before the third or
fourth day, the patient being coma-
tose or delirious. The nervous symp-
toms are so marked that some
waiters have given to this type the
name of cerebral scarlet fever. In a
case of my owii the initial symptoms
were convulsions, hyperpyrexia, and
hematuria.
The writer encountered 16 cases of
scarlet fever with the clinical mani-
festations of meningitis among 400
scarlet-fever patients in the course of
nine months. When the fluid escaped
under high pressure on luml)ar punc-
ture, great relief followed, but when
the pressure was not high, the lum-
bar puncture did not seem to benefit,
SCARLET FEVER (CRANDALL AND MILLS).
79
but it proved very instructive by per-
mitting the exclusion of a suppura-
tive or serous meningitis. The prog-
nosis did not seem to be affected by
the pseudomeningitis, as the severity
of the scarlet fever was what deter-
mined the outcome. Sachs (Jahrb. f.
Kinderheilk., Bd. Ixxxiii, Suppl,
1911).
Surgical Scarlet Fever. — Patients
who have undergone surgical opera-
tions are unquestionably very sus-
ceptible to scarlet fever. Such scarlet
fever, however, is not essentially dif-
ferent from the usual disease. It is
simply scarlet fever in a surgical case.
It is, no doubt, true, as Osier has
shown, that the eruption which has
frequently led to a diagnosis of scar-
let fever is nothing more than the red
rash of septicemia. It is a fact that
surgical scarlet fever is much less
common since surgical septicemia has
become less frequent.
In 12 out of 28 cases of scarlet
fever developed among hospital pa-
tients, the infection followed an ex-
tensive operation and in 1 a severe
burn. The incubation was only three
days in 10 and from five to eight days
in the others. The infection doubt-
less occurred in the operating room.
Kredel (Arch. f. klin. Chir., Bd.
Ixxxvii, nu. 4, 1908).
DIAGNOSIS AND ETIOLOGY.
— Age is first among the predisposing
causes. The disease is rare under one
year, l)ut I have seen an undoubted
attack of scarlet fever in an infant of
one week. Up to 5 years the suscep-
tibility steadily increases and reaches
its maximum; after 8 years it rapidly
decreases, and is slight during adult
life. Sex does not influence its
occurrence.
A patient of the writer developed
typical scarlet fever while nursing
her month-old babe. The disease ran
the usual course without complica-
tions and the infant continued to
nurse and thrive without contracting
the disease. Scarlet fever is rare in
infants less than a year old, and it is
possible, he thinks, that the mother's
milk confers a passive immunity on
the child. Delmas (Arch, des med.
des enfants, Feb., 1911).
Scarlet fever is rare in breast
babies, particularly during the first
six months. It is more common in
boys. The complications during the
first half-year are more frequent and
more severe, the most serious being
gangrenous sore throat, and the most
frequent lymphadenitis. L. V. Ak-
senoff (Roussky Vratch, Sept. 29,
1912).
Of 3603 cases of scarlet fever an-
alyzed by Pospischill and Weiss
there were only 28 cases during the
first year, and these had their in-
cidence during the later months of
the year. The author had the oppor-
tunity of observing 9 cases of scar-
let fever in infants less than 3
months of age and 1 case in an in-
fant 9 months old. With the excep-
tion of the last, all were the infants
of mothers suffering from scarlet
fever.
The clinical phenomena in all of
these cases were somewhat as fol-
lows: From three to seven days fol-
lowing the onset of the disease in
the mother the infant took sick with
a moderate fever lasting from two to
four days. There was the character-
istic tongue with the reddening of
the tonsils and of the soft palate. In
no instance was there any membrane
on or necrosis of the tonsils. There
was at first some difficulty in nurs-
ing and a disinclination to take the
breast. Carl Levi (Beitrage z. Klinik
d. Infektionsk. u. z. Immunit., Bd. ii,
nu. 2, 1914).
That scarlet fever is an infectious
disease does not admit of doubt, but
the specific germ has not yet been
discovered. Three theories have been
advanced as to its etiology, namely,
that it is due to (1) streptococci; (2)
80
SCARLET FEVER (GRAND ALL AND MILLS).
protozoa; (3) a filterable or ultra-
microscopic virus. That it is caused
by a protozoon is possible, but the
theory has by no means l)een con-
firmed. The filterable theory cannot
be excluded, but is largely theoretical.
The scrum of scarlet-fever patients
contains specific antibodies for an
unknown virus. This unknown virus
seems to be present especially in the
cervical lymph-nodes. K. K. Koess-
ler and J. M. Koessler (Jour, of In-
fectious Dis., Nov., 1911).
It has been fully demonstrated that
streptococci play an important role
in the causation of many of the symp-
toms. It has been urged by some that
streptococci are the cause of the dis-
ease itself, but this ground is unten-
able. They are, however, the cause
of the pseudomembranous exudations
of the throat, and undoubtedly cause
the otitis and adenitis, and probably
the nephritis, pneumonia, and joint
lesions. The streptococci thus far
found cannot be differentiated from
other streptococci. The evidence
fails to support the belief that the
streptococcus of scarlet fever dififers
from that of other infectious processes.
The writer examined the blood of
523 children suffering from scarlatina
for streptococci, and concludes that
the organism is found only in 2.1 per
cent, of all cases. V. N. Klimenko
(Arch, des Sci. Biol., St. Petersburg,
No. 3, 1912).
The cause of scarlet fever has
never been definitely determined and
the attempts to transmit it to mon-
keys have met with only very limited
success. The writer believes that it
is a streptococcic infection, though
this assumption has not been proved
or disproved with certainty. Many
clinical facts seem to prove that a
special susceptibility on the part of
the patient is an important factor in
the development of scarlet fever, and
that it may be regarded as an anaphy-
la':tic reaction to a streptococcic in-
fection. Kretschmer (Jahrb. f. Kin-
derhcilk., Sept., 1913).
Whatever the cause of the primary
disease may be proved to be, it is
certain that streptococci are the di-
rect cause of the secondary symptoms.
They are so constant in their pres-
ence, and so active in the production
of the more serious symptoms and
complications, that they must be re-
garded as important factors in the
production of the clinical picture
which we know as scarlet fever. The
disease as it commonly appears is a
mixed infection, the more malignant
and fatal symptoms being due not so
much to the primary as the secondary
infection.
Staphylococci and diphtheria bacilli
are sometimes found in conjunction
with streptococci.
The inclusion bodies studied by
Dohle, of Kiel, have been farther
studied by Nicoll and Williams, of
New York. These are small bodies
found in the protoplasm of the poly-
morphonuclear leucocytes. While
some observers regard them of im-
portance in the diagnosis of scarlet
fever, it cannot be said that their true
significance has as yet been deter-
mined. Thev are rarely found after
the sixth day of the disease.
Other diagnostic signs have in recent
years been proposed, the value of which,
as is the case with Dohle's sign described
above, has not as yet been determined.
Dohle's leucocytic inclosures are
found in many other conditions.
Their absence, however, is of diag-
nostic significance, because they are
found in the early stages of all scar-
let fevers; a negative result therefore
excludes scarlet fever, and the early
diagnosis of the disease may be made
by their presence. A. Belak (Deut.
med. Woch., Dec. 26, 1912).
SCARLET FEVER (CRANDALL AND MILLS).
81
The writer has examined a number
of scarlet-fever patients for the cell
inclusions, 14 with pneumonia and a
number of patients with other affec-
tions, including 11 with anemia and
5 with measles. The inclusions were
found constantly in every case of re-
cent febrile scarlet fever, less numer-
ous in the milder cases and declining
as the disease progressed. After the
seventh day scarcely any were to be
found. They are no aid in diagnosis,
therefore, after the first few days,
and they are not pathognomonic for
scarlet fever, as they occur with the
same constancy and as abundantly
in croupous pneumonia in children.
Schwenke (Miiiich. med. Woch., Apr.
8, 1913).
Leede's sign (Miinch, med. Woch.. Feb.
7, 1911) is obtained in the following way:
Apply a rubber band to the arm suffi-
ciently tight to render the veins very con-
spicuous and the forearms and hands
cyanotic, without obliterating pulse. After
ten or fifteen minutes remove the band.
Put the skin of tlexor surface of elbow on
stretch, to render it anemic. Hemorrhagic
extravasations on this surface, appearing
as very fine, dark points, favor a diagnosis
of scarlatina, while their absence speaks
strongly against the presence of this
affection.
The writer confirms the findings of
Rumpel and Leede in regard to
petechial hemorrhages from artificial
stasis in scarlet fever. He has no-
ticed this phenomenon frequently in
making blood examinations in scar-
let fever, and found it positive in 26
out of a series of 32 cases. In doubt-
ful cases in children, where the
throat signs were suspicious, a posi-
tive result was always confirmed by
the development of typical scarlet
fever. Bennecke (Miinch. med.
Woch., Bd. Iviii, S. 740, 1911).
Study of 100 patients with various
affections to determine the diagnostic
value of the Leede sign. It was not
positive in healthy controls, but was
found positive in heart disease, bron-
chitis, pneumonia, acute hepatitis and
nephritis, cerebral hemorrhage, ty-
phoid and puerperal fevers, and tabes.
These findings deprive the sign of
any specific diagnostic value. It
seems to be a manifestation of dimin-
ished resistance in the walls of the
smaller blood-vessels. U. Morandi
(Gazz. degli Ospedali, Apr. 2, 1912).
The tourniquet or Rumpel-Leede
sign occurs regularly in scarlet fever,
but is found also in measles, and in
some cases of diphtheria, syphilis
and tonsillitis. It permitted an early
diagnosis of scarlet fever in a num-
ber of the writer's cases, before the
eruption developed. Meyer (Deut.
med. Woch., Oct. 24, 1912).
Pastia's sign (La Tribune medicale. No.
46, p. 726, 1910) consists in a deep-rose-
colored, linear exanthem in the skin-folds
of the anterior aspect of the elbow. The
lines are usually two to four in number.
They can be caused to stand out in con-
trast by exerting gentle pressure on skin,
then quickly removing it. It was uni-
formly present in 12) cases, appearing with
the rash and usually lasting two or three
weeks longer than the rash. It occurs in
other diseases, but only in such as can
easily be differentiated from scarlatina.
The Wassermann reaction, according to
Rubens (Berl. klin. Woch., Oct. 19, 1908),
will, under certain conditions that have
remained undetermined, prove positive in
Sicarlet fever as it does in syphilis.
Case of scarlet fever in a girl, 16
years old, in which Wassermann's
test for syphilis produced a posi-
tive reaction. Four weeks after the
commencement of the illness the
test became negative, and remained
so. Holzmann (Miinch. med. Woch.,
Apr. 6, 1909).
The writer examined 55 scarlet-
fever patients and obtained a positive
Wassermann reaction in 18. This
positive reaction occurs after the
subsidence of the acute symptoms
and generally only in the severer
cases. It usually disappears by the
end of the period of desquamation
and has no effect on the diagnostic
importance of the reaction in syphilis.
Jakobovics (Jahrb. f. Kinderheilk.,
Feb., 1914).
8-6
82
SCARLET FEVER (CRANDALL AND MILLS).
The diazo-reaction seems to afford aid
in identifying scarlet fever from measles.
The diazo-reaction was found pcjsi-
tive by the writers in 17.3 per cent,
of scarlet fever, but also 12.9 per
cent, of diphtheria patients during the
first week of these infections. It is
during this week that scarlatiniform
serum rashes are so apt to develop
and make a differential diagnosis from
scarlet fever quite difficult. The per-
centage of positive reactions in
serum sickness was much lower. The
value of the diazo-reaction in dif-
ferential diagnosis is very slight. Yet
the reaction being positive in 75 per
cent, of cases of measles, a negative
reaction in a case presenting a mor-
billiform rash is of value in the dif-
ferential diagnosis from measles.
Woody and Kolmer (Arch. of
Pediat., Jan., 1912).
Copper sulphate may produce a fleet-
ing exanthem and other signs suggesting
scarlet fever.
Copper sulphate is used for spray-
ing grape-vines in France, and 2
children who had been eating grapes
thus sprayed developed symptoms
deceptively simulating scarlet fever.
The diagnosis of scarlet fever was
made without hesitation, but it had
to be revised, as the children were
quite normal again by the fifth day.
Vomiting, sore throat, headache and
a lively rash over the entire body
were the main symptoms. Lasalle
(Arch, de med. des enfants, Feb.,
1916).
Leucocytosis is found in virtually
all cases, the maximum being reached
during- the first week in uncom-
plicated cases. It then gradually
subsides.
Comparing the findings in 10 cases
of scarlet fever with those in 7 of
typhoid, pneumonia, gonorrhea or
gastroenteritis, the writer concludes
that a typical polynucleosis accom-
panies the onset of the eruption in
scarlet fever. It is pronounced and
remains high during the first two or
three days of the eruption, even in
very young children. The number of
mononuclears declines, especially the
proportion of lymphocytes. The
eosinopliiles fluctuate, but are gener-
ally increased, especially by the end
of a few days of the disease. Pater
(Arcli. de med. des enfants, Aug.
1909).
Transmission. — Grave doubts have
been expressed in recent years re-
garding the ability of the desquama-
tion scales to transmit the disease.
No positive statements can be made
until the actual cause of the disease
has been demonstrated. I can only
express the personal opinion that evi-
dence against the belief in the trans-
mission of the disease by desquama-
tion scales and clothing has not been
fully established.
Scarlet fever is not communicable
in the early stages, but is transmitted
mainly by the secretions from the
mouth, nose and ears. The exfoliated
epithelium, after the fourth or fifth
week, does not seem able to carry
contagion. Zangger (Correspondenz-
blat. f. Schweizer Aerzte, Mar. 1,
1909).
Many cases of scarlet fever are so
atypical as to go unrecognized until
a sequela makes its appearance. It
is a disease of direct infection; it is
rarely carried by a second person or
object. The most contagious period
is early in the disease during the
period of angina, rash and tempera-
ture; therefore, the danger of trans-
mitting the disease during the des-
quamation period is much exagger-
ated. Kerley (Amer. Jour, of Dis.
of Children, Jan., 1911).
So long as nasal and aural dis-
charges exist, just so long will cases
of scarlet fever be infective. Sexton
(Arch, of Diag., May, 1915).
Experiments seem to show that the
specific germ of scarlet fever exists in
the blood, for inoculation with the
cerum into susceptible animals pro-
duces a typical attack of the disease.
SCARLET FEVER (CRANDALL AND MILLS).
83
It is also found in the various secre-
tions, as shown by their power to
generate the disease.
The micro-organism, while more
tenacious of life than is that of most
other diseases, either lacks the power
of gaining a foothold, when implanted
in the system, or is less readily con-
veyed through the air. It is at least
a fact that many more children escape
scarlet fever than measles, and its
spread is more readily controlled.
The chief source of infection is the
patient himself, but the area of con-
taoion is limited to a few feet. The
desquamation scales have long been
regarded as extremely infectious.
Their retention by clothing, bedding,
and the walls of the rooms is one of
the most common causes of infection.
The purulent secretions from the
throat, nose, and ear are also very
infectious, and are probably the chief
sources of infection. .
Scarlet fever is spread by indirect
infection more frequently than any
other disease except diphtheria. Its
specific micro-organism is more tena-
cious of life than that of any other
disease, except, perhaps, smallpox.
Authentic cases have been reported in
which it maintained its vitality for a
year or more. It may be conveyed
from one child to another in the fur
of cats and dogs, and it is probable
that these animals may suffer from
the disease. The contagion clings to
rooms with great tenacity, being usu-
ally lodged in the wall-paper or in
cracks of the walls, ceilings, and
floors. The conveyance of scarlet
fever by milk and other articles of
food is undoubted.
The celebrated epidemics of Hen-
don and Wimbledon were believed by
Dr. Klein to be due to scarlet fever
in the cows, but this belief has not
been substantiated. It is probable
that the disease from which those
cows suffered was not true scarlet
fever.
An .epidemic of scarlet fever that
occurred in the city of Evanston, near
Chicago, in the winter of 1906-7
showed conclusively a connection be-
tween the extension of the disease
and the use of milk from a certain
source of supply. This source had
been under suspicion on account of
a number of cases of scarlatina oc-
curring during the previous summer
and fall, but the real epidemic began
early in January, 1907, and was at its
height between the 14th and 19th of
the month. Whole families were at-
tacked in a day, and a notable pro-
portion of the patients were adults.
H. B. Hemenway (Jour. Amer. Med.
Assoc, Apr. 4, 1908).
The disease has been conveyed
by letters written by hands in the
stage of desquamation. An attendant
upon a case of scarlet fever may carry
the infection to other children by the
clothes, hands, or beard.
The portal of entrance in most cases
is undoul)tedly the nasopharynx. It
is here that the first local symptoms
appear, and all the evidence points to
the fact that both the primary and
secondary micro-organisms commonly
enter the system at this point.
In cities scarlet fever is endemic, a
few cases appearing in the health-
reports every week, but at intervals it
becomes epidemic, usually during the
fall and winter. Epidemics of scarlet
fever usually spread very slowly as
compared with those of measles.
Period of Incubation. — The period
of incubation is shorter than that of
any other infectious disease, except,
perhaps, grippe and diphtheria. Tlie
extremes range from a few hours to
fifteen days. In 87 per cent, of cases
84
SCARl.IiT FEVER (C' RANDALL AND MILLS).
Holt found the period to be less than
six days and in 66 per cent, between
1\vo and three days.
Period of Infection. — The period of
infection is long. The disease is not
infectious during the period of incu-
bation, but it may be so from the first
appearance of changes in the throat.
The most actively contagious period
is at the height of the febrile stage:
on the third, fourth, and fifth days.
The infectious power then diminishes,
but increases again during the stage
of desquamation. The period of con-
tagion continues until the last evi-
dences of desquamation have disap-
peared. The purulent discharges
from the throat, nose, and ears are
capable of infecting others, and isola-
tion should not be relaxed until they
have disappeared. The conventional
forty days is not, in most cases, too
long. It should be as much longer as
the condition of the skin and mucous
membranes may indicate.
Report of 45 personal cases in
which children discharged from the
hospital as fully cured of scarlet
fever, the forty-second day, infected
other members in the home to which
they returned. In 6 cases the chil-
dren gave the infection in four days
to other children after their return;
in some others the interval was from
five to twenty-five days, but in the
majority it averaged seven. It is still
a question how long a child with
scarlet fever should be isolated. The
present six weeks' rule is inadequate.
The best plan would be to have spe-
cial convalescent homes for children
with scarlet fever and diphtheria.
Baginsky (Deut. med. Woch., Apr.
18. 1912).
PATHOLOGY. — In uncomplicated
scarlet fever the lesions are confined
to the skin and throat. The lesions of
the skin are those of acute dermatitis.
The papillae and the stratum beneath
become infiltrated with fluid, while
about the blood-vessels there are
aggregations of leucocytes. The pro-
duction of epithelium is greatly in-
creased during the acute stages, which
result later in profuse exfoliation of
the superficial layers. In the later
stages in addition to this, according
to Neumann, there is also a profuse
development of exudative cells, par-
ticularly among the ducts and fol-
licles. These cells easily reach the
epithelial surface : a fact which ac-
counts for the great infectiousness of
the desquamating cells.
The throat changes in uncompli-
cated scarlet fever are catarrhal in
nature, and are an essential part of
the disease. The croupous and diph-
theritic membranes must be consid-
ered as complications. The patho-
logical changes in the tongue are
similar to those in the skin.
Complications and Sequelae. — An-
gina.— Except in a very few mild
cases, the throat always shows some
pathological change. A catarrhal
condition of the throat is normal to
scarlet fever, but membranous exu-
dates and gangrene are not essential
to it.
The true nature of the membranous
inflammation seen in scarlet fever was
long a subject of discussion, which
has been settled by the bacteriologist.
With few exceptions, the angina of
the early stages is pseudodiphtheria,
that of the late stages true diphtheria.
While primary pseudodiphtheria is a
mild disease, the death rate being
rarely over 5 per cent., secondary
pseudodiphtheria is very dangerous
and fatal. The membrane may ap-
pear on the throat on the first or
second day, but it is not usually seen
before the third day. It is generally
SCARLET FEVER (CRANDALL AND MILLS).
85
confined to the tonsils, but frequently
nils the throat and nasopharynx. It
shows a tendency to invade the ears
and nose and to shun the larynx. It
reaches its height about the sixth
or seventh day. It frequently pre-
sents all the local characteristics of
diphtheria together w^ith the general
symptoms of septicemia. The excit-
ing cause of this membranous inflam-
mation is the Streptococcus pyogenes.
It is occasionally associated with the
Staphylococcus aureus or alhus, but the
streptococcus is the more commonly
observed. It occurs not only in the
pseudomembrane and the tissues
underneath it, but is found in the
blood in large numbers. Through the
agency of the toxins which it gener-
ates it is unquestionably the cause of
the complications and general sep-
ticemia. The pseudomembranes which
appear late in the disease are usually
associated with the Klebs-Loffler
bacillus. Diphtheria is, in the fullest
sense of the word, a complication, and
is not an essential symptom of scar-
let fever.
Otitis, next to angina, is the most
common complication, and in its re-
sults is one of the most serious, as it
is a common cause of deaf-mutism.
It results from extension of the in-
flammation from the throat through
the Eustachian tubes. The tendency
to ear involvement varies in different
epidemics, but it is more common in
young patients. It does not usually
occur until the second week, and, as
a rule, involves both ears. Its pres-
ence may be indicated by earache and
an increase in the fever, but fre-
quently a discharge is the first indica-
tion that the ears are involved. The
process is prone to be a destructive
one and to result in long-continued
suppuration. It sometimes leads to a
lapidly fatal meningitis.
Adenitis and cellulitis are com-
mon results of streptococcic invasion
of the throat. Not only are the
lymphatic glands themselves enlarged,
but there is more or less inflammatory
edema of the surrounding tissues.
That this is due to secondary infection
is shown by the fact that streptococci
are found in abundance in both the
nodes and edematous tissues around
them. Enlargement of the nodes may
be detected during the first week, but
serious cellulitis does not, as a rule,
occur until later in the disease. Sup-
puration, sloughing, or even gangrene
may occur.
Joint Lesions. — Although acute ar-
ticular rheumatism sometimes occurs,
the joint affection often called scar-
latinal rheumatism is, in most in-
stances, a synovitis. It is mild, and is
frequently confined to the wrist. It
appears early in the second week, con-
tinues for three or four days, and dis-
appears, suppuration being rare. It
is seldom seen under 4 years. Pyemic
arthritis occurs in extremely rare in-
stances, and affects the larger joints,
the lesions being multiple. Marsden
has recently offered the following
excellent classification of the scar-
latinal joint lesion: (a) synovitis, {b)
acute or chronic pyemia, (c) acute or
subacute rheumatism, and (d) scrof-
ulous disease of the joints.
Nephritis. — Albumin may be found
m the urine during the acute stage ;
but it is fel)rile albuminuria, due to
degenerative nephritis, which sub-
sides as the temperature falls. In the
grave type kidney lesions may occur,
to which the term septic nephritis has
been given. The urine contains albu-
min, but blood and casts are not
86
SCARLET FEVER (CRANDALL AND MILLS).
necessarily present, neither do the
rational symptoms of uremia appear.
The most characteristic and com-
mon kidney lesion is postscorlatinal
nephritis, and is a diffuse nephritis.
It develops during- the third or fourth
week, and may follow a severe or mild
attack. There may be no interval of
apyrexia between the kidney attack
and the onset of the nephritis. It
may be so mild as to almost escape
notice, or it may be so severe as to
cause speedy death. Recovery may
be complete or incomplete. The first
symptom to be noticed is usually
edema of the face, which is frequently
accompanied by feverishness and rest-
lessness. Dropsy and all the charac-
teristic symptoms of acute. nephritis
rapidly develop. The urine usually
shows a small amount of albumin for
a few days before the advent of defi-
nite symptoms. As the disease de-
velops, the urine becomes scanty and
high colored, and may be completely
suppressed. It contains a large
amount of albumin, and is loaded with
blood-cells and casts. The first evi-
dence of albumin after the second
week should be a warning of dan-
ger, and should receive immediate
attention.
Pneumonia, although commonly
found at the autopsy in patients who
have died with septic symptoms, is
frequently not recognized before
death. Endocarditis and pericarditis,
though uncommon, are sometimes en-
countered. Murmurs are occasionally
heard during th^ course of the disease,
which disappear as the active symp-
toms subside. Permanent organic
lesions sometimes develop in conjunc-
tion with the late kidney complica-
tions. Nervous symptoms are rare.
The various serous membranes are
occasionally involved. Peculiar at-
tacks of symmetrical, superficial gan-
grene have been reported. The dis-
ease may be complicated by any of
the other infectious diseases.
Second attacks of scarlet fever are
extremely rare. They sometimes oc-
cur, but in most supposed cases there
has been some error in diagnosis.
Relapses are more common than
second attacks. They result from
autoinfection, and usually occur dur-
ing the second or third weeks.
The writer has met 180 return
cases infected by 145 scarlet-fever
patients dismissed from the hospital
as completely cured and disinfected.
The period of incubation of the re-
turn cases was from three to fifteen
days in 80 per cent, and from fifteen
to twenty-five in the remainder. Of
the 4178 cases of scarlet fever de-
clared during the year in question,
2392 were treated in the hospital in
his charge. None of the adults gave
occasion for the return cases; they
occurred with children who were
much embraced and petted. Preisicn
(Berl. klin. Woch., June 21, 1909).
PROGNOSIS.— The younger the
patient, the greater the mortality.
Holt, after the study of a large num-
ber of American and European cases,
concludes that the general mortality
may be assumed to be from 12 to 14
per cent., while under 5 years it is
from 20 to 30 per cent. It is much
lower in private practice than in hos-
pitals. The majority of fatal cases
occurs in children under 7 years.
The prognosis depends upon: 1.
Amount of poison that has been ab-
sorbed. 2. Whether the child is weak
and delicate or strong and robust. 3.
The occurrence of complications,
especially cardiac, pulmonary, renal,
and otitic. Very high temperature
indicates a bad prognosis. The
younger the child the graver the prog-
SCARLET FEVER (CRANDALL AND MILLS).
87
nosis. Mortality is estimated at from
20 per cent, to 30 per cent, in children
under 5 years of age. Causes of
death: L Scarlatinal toxemia. 2.
Nephritis. 3. Brain abscess from ex-
tension. H. Brooker Mills (Therap.
Gaz., May, 1921).
Prognosis becomes unfavorable on
the appearance of the following symp-
toms, the gravity being in propor-
tion to their severity : Violent onset,
high temperatures, convulsions, ex-
tensive pseudomembranous or gan-
grenous pharyngitis, diphtheria,
croup, pneumonia, extensive cellulitis,
superficial gangrene, nephritis, and
exhaustion with general septic symp-
toms. The prognosis in uncompli-
cated cases is good.
Sudden death is not uncommon in
this disease, and is usually due to
myocardial trouble. Weill and Mouri-
quand (Presse med., Aug. 5, 1911).
Morbidity of over 7,000,000 cases
collected and studied from communi-
ties in America, Europe and else-
where. The most striking fact about
case-fatality of scarlet fever in the
past half-century has been its con-
sistent, general and marked reduc-
tion. The sexes, as a whole, show
about equal susceptibility. During
the first five years of life males are
more susceptible to the disease, while
between 5 and 15 years females are
distinctly more susceptible. Case-
fatality is higher among males at all
ages. Nearly half of the scarlet fever
cases was found to occur in the five
years between 3 and 8 years of age,
distributed nearly equally in each of
the five years, and 2 children out of
3 at this age contract the disease,
when exposed to it in their homes.
Ninety per cent, of cases occur un-
der 15 years of age. Mortality is
highest in infancy, being from 12 to
20 per cent.; lowest at about 10 years
of age, and thereafter gradually in-
creases with age. About 90 per
cent, of deaths occur under 10 years
of age. H. H. Donnally (Wash.
Med. Annals, Nov., 1915).
PROPHYLAXIS.— In view of the
gravity of the disease and the efifect-
iveness of preventive measures, pro-
phylaxis assumes unusual importance.
The most important of all prophylac-
tic measures is complete isolation of
the sick. This applies to nurse as
well as to patient. If possible, one
'person should be selected as an inter-
mediary between the nurse and the
family. The doctor should always
wear, in the sick-room, a gown of
muslin or calico fastened at the neck
and waist, and long enough to com-
pletely cover his clothes. A stetho-
scope should be used in making phys-
ical examinations of the chest.
The period of isolation should not
be less than forty days and as much
longer as the presence of desquama-
tion or purulent discharges may de-
mand.
The best prophylactic treatment is
the removal of enlarged and diseased
adenoids and tonsils.
Scarlet fever having appeared in 2
pupils in a school of over 300, the
2 patients were at once isolated and
the throats of all the contacts sprayed
with a 1 : 2000 solution of mercury
perchloride. No other cases ap-
peared, and the remaining children
appeared in perfect health, save for
the fact that in 131 cases out of the
remaining 299 an elevation of tem-
perature varying between 99° and
101° F. (37.2° and 38.3° C), and last-
ing for two or three days, was found.
There were absolutely no other
symptoms or indications of the chil-
dren being out of sorts. Thornton
(Brit. Med. Jour., Feb. 29, 1908).
In the last 28 years 4251 cases of
scarlet fever have been reported at
Brunn. Sterilization of the premises
and measures to prevent infection of
others failed in a large number of
88
SCARLET FEVER (CRANDALL AND MILLS).
cases. It is evident that the virus is
transmitted not only in the period
of incubation, but long after recov-
ery, far beyond the routine six
weeks. The aim should be to re-
move the virus from tlie mouth by
mechanical means. Kokall (Wiener
klin. Woch., Dec. 29, 1910).
Numerous observers of late, espe-
cially in England, have shown that
by the cleansing treatment of nose
and throat with a mild antiseptic
healthy children could be kept in con-
tact with children ill with scarlatina
without contracting the disease. The
writer has treated 2 families, 6 chil-
dren in each family, where one mem-
ber had contracted scarlatina, and by
the simple process of cleaning the
nose and throat three times a day for
six weeks he has prevented any fur-
ther spread of the disease. Schultze
(Med. Rec, Dec. 10, 1910).
Dischargees from the patient should
be disinfected with strong subHmate
sokitions. The bedding, carpet, and
clothinp- should be disinfected with
boiling water or steam. The mat-
tress should be destroyed. The room
itself should be thoroughly washed —
floor, ceiling, and walls — with a
1 : 2000 sublimate solution.
One room on the top floor of every
house should be arranged for a sick-
room : the moldings should be plain,
and the floor of hard wood ; the walls
and ceilings should be painted or cov-
ered with washable paper ; the bed-
stead should be of enameled iron. It
is a fallacy to suppose that dishes in
the sick-room, filled with antiseptic
fluids, can limit the spread of the dis-
ease, or that there is any efficiency, as
a prophylactic, in generating steam
impregnated with medicinal agents.
The use of such agents is liable to
generate a false sense of securitv and
lead to the neglect of more important
measures.
[The child should have its own
dishes. Everything should be disin-
fected before it leaves the room — i.e.,
sheets, pillow-cases, towels, and
everything used for the patient — in
bichloride of mercury solution 1 :500
or phenol solution 1:50; also the
urine and feces, which should be col-
lected in a bed-pan containing equal
parts chloride of lime and strong vine-
gar. So far as possible use materials
that can l)e burnt. Diapers could be
made of old sheets, and napkins could
be made of paper. Hang a sheet at
the door and keep it wet with either
of the solutions! mentioned, as this
will catch the dust from the outside
and infected material from the inside
of the room. Sprinkle one of these
solutions on the floor, or mop once or
twice a day. Have a gown and cap
handng- at the door and a pair of rub-
ber overshoes for your own use.
Take the tjown off at the door of the
sick-room, and have it disinfected be-
tween visits. When you leave the
room, go to the bath-room and wash
the hands and face in a weak bichlo-
ride solution. The mail should also
be carefully disinfected before it
leaves the house, using dry heat, and
all animals kept out of the sick-room
during the illness, as they are great
carriers of the infection. — H. Brooker
Mills.]
Streptococcic vaccines have been
tried. The most satisfactory of these
so far has been Gabritschewsky's,
reference to which has already been
made on page 342 in the second vol-
ume of the present work.
Gabritschewsky's vaccine for scarlet
fever is made from streptococci iso-
lated from the blood in the hearts of
children dead of scarlet fever. It is
a condensed bouillon culture of
SCARLET FEVER (CRANDALL AND MILLS).
89
streptococci killed by heating to 60°
C, and the addition of Yz per cent,
carbolic acid solution. Each c.c. con-
tains 0.02 to 0.03 of the bacterial
mass. The vaccine was first used in
Moscow in 1904. Usually 10 drops
were injected with an ordinary hy-
podermic syringe. The injections
were made during an epidemic of
scarlet fever, 185 persons being thus
treated, as a preventive measure. A
rise of temperature was observed in
all but one. A moderate rise in 64
persons, a faint rise in 54, a marked
rise in 66. Local tenderness was
seen in 66 patients, redness in the
injected area in 173; swelling in 103.
In many cases there was a rash re-
sembling true scarlet fever, and in 5
patients there was desquamation.
There was a general rash in 43 per-
sons, a local rash in 70; no rash in
72 of the 185 patients; only 2 devel-
oped scarlet fever; the remainder re-
mained well, save that they showed
these temporary complications after
the use of the vaccine. Schamarine
(Roussky Vratch, June 30, 1907).
The streptococcus vaccines, used as
advocated by Gabritschewsky, have
some influence in controlling epi-
demics of scarlet fever. Their use,
with proper care, is attended by no
harmful results. They should be
given a wider application in this
country to prove or disprove the con-
tentions of the Russian physicians.
Smith (Boston Aled. & Surg. Jour.,
Feb. 24, 1910).
After using the Gabritschewsky
vaccine in 700 cases the writer con-
cluded that it had a decided value
from a prophylactic standpoint. In
comparing the effects observed he
states that but one very light case of
scarlet fever has occurred among the
nurses who have received vaccine
treatment, while in a considerably
smaller group, under identical condi-
tions, 5 developed severe cases of
scarlet fever. Walters (Jour. Amer.
Med. Assoc, Iviii, 546, 1912).
During a severe epidemic of scarlet
fever in a number of villages the
writer used Gabritschewsky's bac-
terins, making about 3000 inocula-
tions. The results were very satis-
factory. It was found, however, that
a single inoculation does not confer
immunity, and that immunity does
not last over six months. Poloteb-
nova (Roussky Vratch, July 14,
1912).
[A physician should not attend an
obstetric case while in attendance
upon a patient suffering with scarlet
fever. — H. Brooker Mills.]
TREATMENT.— Many specifics
for scarlet fever have been proposed,
tried, and found wanting. Much may
be done to avert complications and to
render them less serious when they
occur, and many lives may be saved
by judicious management. Mild cases
require little or no medication ; they
usually receive too much.
The patient should be kept in bed
for at least three weeks, and should
receive a fluid diet for not less than
two weeks. Milk is the best diet for
scarlet-fever patients. It may be
given peptonized or plain. Later in
the disease broths, eggs, or meat-
jellies may be given. The stoinach
should never be overfilled.
[The diet should be liquid and
nourishing. If the child is breast-fed,
have the milk pumped from the breast
and fed to the child. If a bottle baby,
dilute one-half with water if on
straight milk, because whole milk
constipates and causes tympanites, or
give half milk and half Vichy water,
because alkalies help to neutralize the
acidity, which is one of the causes of
the nei:)hritis. Orange juice is very
beneficial. Lemonade is good, espe-
cially if one adds to every pint (500
c.c.) 1 dram (4 Gm.) of cream of tar-
tar. Cereals may be cautiously added,
and water should be given freely.
90 SCARLET FEVER (CRANDALL AND MILLS).
Avoid the use of salt and exclude The throat symptoms of the first
soups and bouillon from the diet. — few days may be mitif^^ated by giving-
H. Brooker Mills.] cool water or bits of ice. Later hot
The initial vomiting usually re- drinks may be given or irrigation of
quires no treatment, ]:)ut the bowels the back of the throat with a weak
should be acted upon mildly by small, hot saline or boric acid solution may
repeated doses of calomel. Later be employed. Chlorate of potash
they should be kept acting, if possible, should l)e avoided. Its beneficial
by means of enemata rather than by efifects are doubtful. Nasal syringing
the use of cathartic drugs. should be avoided unless clearly in-
In severe cases stimulants are re- dicated by a purulent nasal discharge
quired. In malignant cases they or obstruction of the nasopharynx,
should be pushed to the point of More harm than good may result from
tolerance. Strychnine is of great overzealous attempts at local treat-
value in septic cases with prostration ; ment of the throat and nose. The
it may often be combined to advan- most successful treatment consists in
tage with digitalis. Bathing the sur- the use, not of active and poisonous
face with warm water followed by antiseptics, but of mild and cleansing
anointing with plain or carbolic vase- washes, freely and frequently applied.
lin or a 5 per cent, ichthyol ointment [As to the toilet of the nose and
should be begun as soon as the first throat: Swab, spray, or gargle with
signs of desquamation appear, and alkaline solution, according to the age
should be continued throughout the of the child. If the patient be old
course of the disease. enough to gargle, this should be
For the itching, which is sometimes done ; if, on the other hand, it be too
intolerable, keeping the .child restless young for that, but old enough to
and irritable, the writer finds spong- opg^ J^S mouth and put out its tongue
ing the body with a warm solution i ^. u *. j ,i i i •
, ,. u . / • .- when told to do so, then swabbmg
of sodium carbonate (gram x — Gm. i i , •, .
0.6-to-5j-60 c.c), to which a little "^''^y ^'^ employed, while, if it be too
mucilage has been added, very useful young to do this, spraying with an
and soothing. Seymour Taylor (Med. atomizer would be better. Potassium
Bull., Aug., 1907). permanganate, gr. ss (0.03 Gm.),
Tepid baths (28° to 32° C.-82.4° to ^^ter f,j (30 c.c), is a good solution
89.6° F.) of 20 minutes' duration and , r .• it-,
., to use lour times a day. Do not use
given every evening, or it necessary, . , ,
morning and evening, will often in- Potassium chlorate for the sore throat,
duce sufficient sedation. The un- because of its well-known irritating
pleasant sensation of heat in the skin effect on the kidneys should any of it
is also allayed by such baths, though be swallowed or absorbed. After
still more effectually by rubbings .,^; .i ii i- i i.- • --i r
.,, r • using the alkaline solution instil a few
with the following liniment: — , . , •■, . .,
■drops m each nostril of anv oily prep-
Cold cream, _ aration, such as :-
Neutral glycerin aa 50 Gm. (12 'jr).
M. Ft. linimentum. ^ Menthol gr. x (0.65 Gm.).
The liniment should preferably be '^''^"'^^ ''^^ &''• 'J ^^-^^ Gm.).
used luke-warm. A. F. Plicque 01. eucalypt fSss (2.0 c.c).
(Med. Bull.; N. Y. Med. Jour., July Liq. albolem ....q. s. fSij (60 c.c).
27, 1912). H. Brooker Mills.]
SCARLET FEVER (CRANDALL AND MILLS).
91
Adenitis can only be controlled by
checking the septic process at its
fountain-head in the throat. The ap-
plication of hot oil or the hot-water
bag is soothing to some patients, but
the use of cold is preferable in most
cases. Poultices should not be ap-
plied continuously. Diffuse suppura-
tion requires free incision. Otitis re-
quires the treatment demanded by the
disease in other conditions. The
joint affections require but little treat-
ment other than rest and protection.
Rheumatism should receive its own
appropriate treatment. Restlessness
and nervous symptoms are sometimes
relieved by cold to the head, or by the
use of small doses of phenacetin, not
enough being given to materially
affect the temperature. Nephritis
should receive prompt and very care-
ful attention. Tts treatment is that of
nephritis due to other causes.
A study of 325 cases, with 23
deaths, in the Alexandra Hospital,
Montreal, showed that twenty-one
days' milk diet and twenty-one days'
bed should be the rule to prevent
death from nephritis J. McCrae
(Montreal Med. Jour, Sept., 1908).
The temperature may require atten-
tion from the outset, but it should
not be forgotten that a high tempera-
ture IS normal to scarlet fever. It
may be allowed to run, therefore,
without interference, to a somewhat
higher point than in most other dis-
eases. Hyperpyrexia, or a tempera-
ture continuously above 104° F.
(40° C), demands treatment. It is
best reduced by means of the cold
bath; l)Ut this, for obvious reasons, is
less practical in private than in hos-
pital practice. The cold pack or cold
sponging are more available. An
effective method of applying cold
adopted at the Willard Parker Hos-
pital IS thus described by Northrup:
"The tendency in all cooling processes
is for the feet to become cold. To
obviate this the patient is placed upon
blankets, but the legs, feet, arms, and
hands are wrapped in warm, dry
blankets, and hot bottles are inclosed
in the wrappings. An ice-bag is ap-
plied to the head. The face and
trunk are freely sponged in wann
water and alcohol, evaporation being
hastened by fanning, so long as it
cools the patient, clears the cerebrum,
gives force and improved rhythm to
the heart, and leaves the patient to a
quiet sleep."
Great caution should be exercised
in the use of antipyretic drugs. No
coal-tar antipyretics should be used.
[Treat the temperature hydrothera-
ipeutically — i.e., sponge baths, colonic
irrigations, ice-bags, etc. In cases of
very high temperature, and especially
with diminution of urine, once a day
wrap the child in a blanket and place
it in water at a temperature of 90° to
95° ; keep it there for from 10 to 12
minutes ; take out of wet blanket and
place in dry blanket, and give inunc-
tion of cacao butter. Try to have two
rooms, one for day and one for night,
preferably with a sunshine exposure.
Keep temperature of rooms at 68° to
70° F.— H. Brooker Mills.]
In all cases in which hypodermic
injections of large doses of quinine
bihydrochloride were given the infec-
tion was cut short. The fever yielded
after the second or third injection,
desquamation rapidly supervened, and
prompt recovery followed. A. Tram-
busti (Semaine med., June 18, 1913).
The writer uses quinine bihydro-
chloride, giving a 30 per cent, solu-
tion hypodermically in full doses. A
single injection is said to reduce the
temperature rapidly and to improve
92
SCARLET FEVER (CRANDALL AND MILLS).
the subsequent course. Chichkine
(Gac. Med. Catalan., Jan., 1915).
Serum treatment has been tested
very extensively, but 1 feel con-
strained to say that up to the present
time it has not proved of the value
hoped for. It is certain that the stock
antistreptococcus serums have not
shown themselves to be of striking
value. Decided results have been
claimed for Escherich and ]\Ioser's
serum, but it has not been generally
adopted. Inasmuch as the more
serious symptoms of scarlet fever are
all largely due to streptococcic infec-
tion, the theory underlying the use of
normal serum is not irrational. At
the present writing, however, no posi-
tive statements can be made regard-
ing its efificacy.
[The value of antistreptococci
serum is doubted and its use is
limited. There are several conditions
where one would not use the serum :
1. In cases with very high tempera-
ture. 2. In very young infants or pa-
tients who are greatly exhausted from
the effects of the disease. If indi-
cated, use 20 to 40 c.c. every 4 to 6
hours. The prophylactic dose to
others is 10 c.c, but a single inocula-
tion does not confer immunity, and
immunity, when present, does not last
over 6 months. — H. Brooker Mills.]
More promising results have been
obtained from serum of convalescents.
In a recent malignant epidemic of
scarlatina at Stockholm, convalescent
serum was obtained from the fourth
to the seventh week of the disease,
and 0.5 per cent, of phenol added. It
was then used exclusively in des-
perate cases, with intense intoxica-
tion, bad mental state, pulse 140 to
160, cyanosis, fever 40° to 41° C—
cases in which recovery would aver-
age much less than 50 per cent. Of
237 cases sufficiently serious to re-
ceive serum, 195 recovered, while 25
died in the first and 17 in the second
week of the disease. Of the 195
cures, 101 were very prompt. In 91
cases of the same type who received
no serum the mortality was 70 per
cent. Mild cases can supply serum
as potent as severe cases. Kling and
Widfelt (Hygiea, Jan. 16, 1918).
In treating severe scarlet fever
witli convalescent serum, the blood
was drawn from the twentieth to the
twentj--eighth day. Serums from sev-
eral patients were mixed, tested for
sterility, and stored in the refriger-
ator. The serum was injected intra-
muscularly in the thighs in doses of
25 to 90 c.c. (6% drams to 3 ounces),
60 c.c. (2 ounces) being tlie usual
dose. Commonh' a single dose was
given, occasionally 2. Xo local or
general disturbances followed. Nine-
teen cases were thus treated. Quite
constantly a fall of temperature be-
gan two to four hours after the in-
jection and continued gradually for
twelve to twent}--four hours. In
purth- toxic cases the temperature
fell to nearly normal and tended to
remain there. In cases with septic
complications it rose again after the
fall and ran a "septic" course. Weaver
(Jour, of Infect. Dis., Mar., 1918).
Report of favorable results in pro-
phylaxis of scarlet fever by the use
of a sere vaccine obtained from the
desquamated scales of scarlet fever
patients. Horses treated with it de-
veloped antibodies in their serum to
an amboceptor power of 2000. Of 40
children immunized and allowed to
live and sleep in the same bed with
scarlet fever patients, not one con-
tracted the disease. Of 25 children in
families where there was a case of
the disease, not one contracted it.
The immunized children were fol-
lowed for si.x months, and the per-
sistent presence of the amboceptors
confirmed. Di Cristina and Pastore
(Pediatria, Jan., 1919).
According to Ramond and Schultz,
sodium salicylate possesses to a cer-
tain degree specific properties.
SCARLET FEVER (CRANDALL AND MILLS).
93
Sodium salicylate is indicated in
scarlatina. It should be given from the
start, but on the fifth day discontin-
ued, and resumed from the fifteenth
to the twentieth day, when late com-
plications are due. The dose is about
6 Gm. (90 grains) per day, increased
to 8 Gm. (2 drams) or more if re-
quired. Nocturnal exacerbations be-
ing typical in scarlet fever, the drug
should be continued during the night.
At the fifteenth day the dosage need
not be as large. Under this drug the
fever subsides by the third day. The
throat lesions are rapidly reduced, but
with the recrudescence at the fifteenth
day, may reappear in an aggravated
form. They are rapidly controlled by
the salicylate. The latter may abort
late nephritis if given in time, but if
the complication has several days'
headway, should be given cautiously,
lest the kidneys be unable to excrete
it. If it can pass the kidneys the dose
may then be augmented. On all other
manifestations of the disease, the
drug acts more or less as a specific.
Ramond and Schultz (Jour, de med.
de Paris, Sept., 1916).
Salvarsan, and especially neosal-
varsan, have been much lauded, but
neither has stood the test of experience.
[But little medicine should be
given, but the free use of water is
necessary. The one and only drug"
that is usually necessary is potas-
sium citrate in 2- to 5- grain (0.13 to
2 Gm.) doses, or liquor potassii
citratis, 15 to 20 minims (0.9 to 1.25
c.c.) three times a day. Sweet spirit
of nitre should not be given freely.
The skin in scarlet fever is not active,
and therefore there is no use for a
diaphoretic ; as for diuretics, the pos-
sibility of damaged kidneys should
always be borne in mind. If renal
inflammation develops, poultices ap-
plied over the kidney region may do
good. Make flaxseed poultice with 16
parts flaxseed and 1 part mustard, or
4 parts flaxseed and 1 part digitalis
leaves. Put on every four hours dur-
ing the day, and keep on hot for half
an hour. For stimulation, when
needed, caffeine sodium-benzoate in
%-grain (0.03 Gm.) doses hypoder-
inically is among the best. Digitalis
and strophanthus, the latter especially
in very young children, may be em-
ployed by mouth. Itching is very
troublesome during desquamation in
scarlet fever; warm baths followed
by cacao-butter inunctions are very
helpful.— H. Brooker Mills.]
As emaciation and anemia are fre-
quent results of scarlet fever, active
tonic treatment should be instituted
during the convalescence, the chief re-
liance being placed upon iron. Bash-
am's mixture is especially indicated.
The patient should be particularly
protected from cold, for exposure not
infrequently seems to precipitate
nephritis long after its usual period of
occurrence.
When the depression becomes
threatening the use of adrenalin
sometimes proves very beneficial, as
shown by Hutinel. The 1 : 1(X)0 solu-
tion may be slowly injected intra-
muscularly in saline solution, the dose
varying with the age, from 5 to 10
minims, repeated every hour or two.
The blood-pressure was found in a
series of cases to be subnormal in 25
per cent. Pronounced arterial hy-
potension, especially if accompanied
by other signs of acute suprarenal
insufficiency, should be treated by
adrenalin. J. D. Rolleston (Brit.
Jour, of Children's Dis., Oct., 1912).
The writer found adrenalin very
useful in tiding the patients past the
danger point when the adrenals
seemed to be suffering acutely from
the infectious toxic process. Cam-
phorated oil, also proved surprisingly
effectual. P. H. Kramer (Neder-
94
SCHLAMMFIEBER.
SCLERODERMA.
landsch Tijdschrift v. Geneeskunde,
Sept. 6, 1913).
In the writer's service there were
34 cases of malignant scarlet fever
in a total of 550 cases of this disease;
in a previous series of 833 cases there
were 27 that terminated fatally. Re-
covery was the rule in destructive
lesions in the throat; the defects in
the tissues were filled in time and no
operation was required. Hutinel
(Arch, de med. des cnfants, Feb. 1915).
Floyd M. Cr.and.all,
New York,
AND
H. Brooker Mills,
Philadelphia.
SCHLAMMFIEBER. -This name
was applied to a form of acute infectious
jaundice which occurred among young
subjects who had worked in the districts
of Breslau that had been recently flooded.
It is not entitled to classification as a
disease, since it corresponds in every way
with acute infectious jaundice (Weil's dis-
ease), treated on page 394 of the sixth
volume of the present work.
SCLERODERMA.-DEFINITION.
— A disease characterized by induration
of the skin, and at times of the sub-
cutaneous tissues, which sometimes pro-
gresses to complete atrophy of these
tissues.
VARIETIES.— Three main varieties of
scleroderma are recognized: the diffuse,
which is generalized or limited to certain
areas; the circumscribed, or morphea,
which appears in spots; and sclerodac-
tyly, which is limited to the hands.
SYMPTOMS.— In the diffuse form,
after a series of prodromic symptoms,
sensations of chilliness or heat, pruritus,
and pain in the muscles and articulations,
the tissues becoming thickened, stifif, and
hard, and appear edematous. The skin
is cold and whitish, contracted, and some-
times painful. The face and the upper
part of the body may be the only parts
aflfected, but the entire body becomes in-
volved. The skin is, as it were, glued to
the skeleton, the fingers and toes being
thin and stifif or hooked. A variable
amount of pigmentation is usually pres-
ent in well-developed cases. Gangrene
is sometimes observed, constituting the
mutilating form.
In the circumscribed variety, the mor-
phea of Erasmus Wilson, the affected
spots are limited in area, the spots being
flat or raised, oval or rounded. Their
color varies from a light pink to a pale
or dark violet, and undergoes changes
which ultimately give the lesion a
characteristic aspect: a whitish-brown
squamous center surrounded by a bluish
or lilac pigmented border, or ring. They
are seldom painful, though pruritus is
sometimes complained of. The spots, of
which there are generally but two or
three, are usually located upon the neck,
the chest, the abdomen, the arms, or
the thighs. These spots gradually fade
away, but occasionally cicatrices are left
to mark the location of the lesions. The
prognosis in this form is favorable.
In sclcrodactyly the third phalanx be-
comes atrophied and its tissues, including
the nail, are partially destroyed by ab-
scess. The flexor tendons are contracted
and give the finger the appearance of an
angular hook by flexing the first phalanx
upon the second. Here also the skin is
hard, contracted, adherent to the bones,
and lilac in color. The prognosis is
necessarily unfavorable, owing to the
mutilations caused by the disease.
DIAGNOSIS.— The only condition with
which scleroderma can be easily con-
founded is leprosy, but the tubercles of
the latter disease, the broad dissemina-
tion of the skin lesions, the nasal dis-
order, the character of the ulcerations,
and the disturbances of sensation usually
facilitate its recognition.
Osier observes that diffuse scleroderma
must sometimes be distinguished from
brawny, solid edema, met with at times in
patients with long-standing renal or car-
diac disease, in which there is induration
following chronic dropsy. In scorbutic
sclerosis there may be parchment-like
immobility of the skin, due to extensive
subcutaneous hemorrhages, involving the
muscles.
During the stage of swelling it may
resemble myxedema. In Raynaud's dis-
ease the infiltration, pigmentation, and
extreme cyanosis are not wholly unlike
those of scleroderma. The increase of
SCOPARIUS AND SPARTEINE (WITHERSTINE).
95
pigment may suggest Addison's disease,
since the bronzing may be extreme.
ETIOLOGY AND PATHOLOGY.—
Scleroderma is an angiotrophoneurosis,
most frequently observed among neurotic
subjects and often in connection with
the rheumatic diathesis. It may appear at
any age, but chiefly in early adult life,
and is more prevalent among women than
men. The neurotic influence, however,
does not account for all cases, nerve-
changes being wanting in the majority.
Exposure to cold and wet, rheumatism,
nerve shocks, menstrual disorders, trau-
matism, etc., are named as causes.
Kaposi notes that the lesions follow,
to a degree, vascular distribution. The
morbid changes peculiar to scleroderma
include an endoperiarteritis, which may
be traced to various structures: the mus-
cles, the myocardium, the uterus, the
lungs, and the kidneys particularly. The
sclerosis would thus seem to be a result
of the vascular disturbances, through
impaired nutrition of the aflfected areas.
The chief changes in the skin, according
to Schamberg, are an increase and con-
densation of the connective tissue in the
corium and the subcutaneous tissue, an
increase in the elastic tissue, and a dimi-
nution in the caliber of the blood-vessels.
Later atrophy of the subcutaneous tissues
occurs.
Reines reported 13 cases which seemed
to confirm the connection between sclero-
derma and tuberculous infection.
Of 5 cases of diffuse scleroderma exam-
ined by Whitehouse, 3 gave a strongly
positive Wassermann reaction, 1 a faintly
positive and 1 a negative reaction.
According to Ravogli, 1917, the under-
lying factor in the disease is a disturbance
of equilibrium of the internal secretions of
the adrenals, thyroid, etc., while exposure
is often the determining factor. Criado,
1918, obtained improvement in one case by
adrenal administration, and made the sug-
gestion that adrenin be also used locally.
PROGNOSIS.— The prognosis is ex-
ceedingly unfavorable as regards cure.
The disease usually persists throughout
life. Improvement occurs in quite a third
of the cases. In adults Lewin and Heller
report 16 per cent, of cures, and 31 per
cent, in children under 15 years of age.
TREATMENT.— The treatment con-
sists in nutritious diet, good hygienic
surroundings, iron, and codliver oil in
ascending duses (the latter up to 10 table-
spoonfuls per day); sodium salicylate; ex-
ternally, steam baths, mud baths, mer-
cury (by inunction), galvanism, and mas-
sage. The most recent remedy is thyroid
gland; but, according to Osier, it is not
of much value. Brocq recommends elec-
trolysis, at first at comparatively short
intervals; then, when amelioration is
manifest, at much longer intervals. Elec-
trolysis does not act by destructive action,
but at a distance, influencing even patches
not touched. Philippsohn obtained excel-
lent results by the administration of
salol, in doses of about 7 to 15 grains
(0.45 to 1 Gm.), three or four times daily.
S. and W.
SCLEROSIS. See Index.
SCOLIOSIS. See Spine, Diseases
AND Injuries of.
SCOPARIUS AND SPARTE-
INE.— Scoparius, N. F. (spartium,
broom, broom-tops, besom), is the
dried tops of Cytisus scoparius (fam.,
Leguminos?e), a densely growing
shrub indigenous to Europe and ad-
jacent Asia, and sparingly naturalized
in sandy soil in North America. Its
long, slender, erect, and tough twigs
are arranged in large, close fascicles
which lie parallel with and close to
one another, and have a peculiar odor
wdien bruised, and a disagreeably bit-
ter taste. The quality of the drug
deteriorates with keeping, the pecu-
liar odor of the recently dried drug
being partially or completely lost.
Broom contains two active princi-
ples, sparteine and scoparin.
Sparteine (Cir,H26N2) is a trans-
parent, oily liquid, colorless when
fresh, but turning brown on exposure,
having an odor resembling that of
aniline, and a very bitter taste. Spar-
teine is heavier than water. It is but
96
SCOPARIUS AND SPARTEINE (WITHERSTINE).
slightly soluble in water, but readily
dissolves in alcohol, ether, and chloro-
form, and is insoluble in benzene and
benzin. Sparteine contains the car-
diac properties of scoparius.
The official sulphate of sparteine is
prepared by dissolving- 10 parts of re-
cently distilled sparteine in 40 parts
of diluted (10 per cent.) sulphuric
acid, and allowing the solution to
crystallize in a warm place. It should
be kept in well-stoppered, amber-col-
ored vials. Sparteine sulphate occurs
as colorless, rhomboidal crystals, or
as a crystalline powder, odorless, but
having a slightly salty and somewhat
bitter taste, soluble in 1.1 parts of
water, 2.4 parts of alcohol, but in-
soluble in ether and chloroform. It
is hygroscopic, and its aqueous solu-
tion has an acid reaction.
Scoparin (C21H22O10) is a gluco-
side, occurring in pale-yellow crystals,
without odor or taste, and soluble in
alcohol, alkalies, and in hot water. It
probably represents most of the diu-
retic properties of scoparius.
PREPARATIONS AND DOSES.
— The only official preparation is : —
Sparteincc sulphas, U. S. P. (sparte-
ine sulphate). Dose, y^ to 2 grams
0.008 to 0.13 Gm.).
Unofficial but serviceable prepara-
tions are : —
Scoparius, N. F. (broom-tops).
Dose, 15 to 60 grains ( 1 to 4 Gm.).
usually in decoction.
Decoctum scoparii (decoction of
broom, made by adding ^ ounce —
16 Gm. — to 1 pint — 500 c.c. — of water,
and boiling down to /^ pint — 250
c.c). Dose, 1 ounce (30 c.c.) to be
taken every three hours,
Fluidextractum scoparii, N. F.
(fluidextract of broom). Dose, 15 to
30 minims (1 to 2 c.c).
Infusum scoparii, Br. P. (infusion
of broom, made by adding 2 ounces —
60 Gm. — of dried and bruised l)room-
tops to 20 ounces — 600 c.c. — of boil-
ing distilled water; infusing in a
covered vessel for fifteen minutes and
straining). Dose, 1 ounce (30 c.c.)
every three hours.
Scoparin (the glucoside). Dose, 8
to 15 grains (0.5 to 1 Gm.).
PHYSIOLOGICAL ACTION. —
Internally broom, in large doses, ex-
cites vomiting and purging, and in
smaller doses increases the urinary
output. Sparteine acts upon the
heart as a stimulant or tonic like
digitalin, wiiile scoparin exerts its
action upon the kidneys. Sparteine
has a decided elTect upon the nerves
and spinal cord, lowering reflex ac-
tion, paralyzing motor nerves, reduc-
ing the electrical excitability of the
vagus and, finally, causing death by
paralysis of respiration, both as a re-
sult of its action upon the center and
upon the respiratory muscles.
In its action upon the circulation
sparteine, according to most observ-
ers, causes a transient rise in ar-
terial pressure, followed by a longer
period of diminished vascular tension.
Laborde, however, claims that spar-
teine has no influence on the blood-
pressure. Small doses slow the heart
for a short period and then accelerate
it, the volume of the pulse being sim-
ultaneously increased. Large doses
cause marked depression of the car-
diac muscle, and of the vagus. The
heart responds to its action in about
twenty to thirty minutes, and the
efifect continues for from six to eight
hours.
No cumulative action has been ob-
served. When taken regularly for
several weeks, the effects continue for
SCOPARIUS AND SPARTEINE (WITHERSTINE). 97
several days after discontinuing the solved in water with a trace of am-
remedy. monia, or in a mixture of 1 part of
In its action on the muscles, D. glycerin and 3 parts of water, given
Cerna demonstrated that sparteine hypodermically.
causes a brief period of increased Sparteine is pre-eminently a heart
muscular irritability, that it augments tonic and heart regulator, rapid in its
reflex action by a direct influence action, certain in its effects, and pro-
upon the spinal cord, this increase be- ducing a regulation of the heart's
ing followed by a subsequent depres- pulsations in more ways than one.
sion, that it gives rise to convulsions If the pulse rate is below normal, it
of a spinal origin and generally will cause acceleration, but if above
tetanic, that it causes a primary in- normal, it will bring it down,
crease in the rate and force of the Laborde calls it the "cardiac met-
heart's action by a direct influence ronome." In weak and irregular
upon the heart, the increase being heart Germain See advises doses of
soon followed by a decrease, due to from ^ to % grain (0.016 to 0.01
direct cardiac action and stimulation Gm.) every four hours. In heart-
of the cardioinhibitory centers ; it aug- failure, the result of mitral disease, it
ments the blood-pressure by an action gives the best results. In valvular
upon the heart, and also by stimulat- disease, with defective compensation,
ing the central vasomotor system ; the small doses are apparently more efifi-
arterial pressure subsequently de- cacious than large ones. Shoemaker
clines, owing to paralysis of the vaso- has found sparteine of service in
motor system and a direct depressant cases of enfeebled cardiac action from
action upon the cardiac musculature, structural lesions, and also where the
It is claimed that sparteine strongly innervation of the heart was markedly
and promptly reduces the size of the disturbed. In mitral disease it is
heart. particularly valuable, even in the ad-
THERAPEUTIC USES.— In re- vanced stage, when dilatation has be-
nal insufficiency with deficient urin- gun. In cases of dyspnea, palpitation,
ary secretion, due to lowered* arterial and cardiac debility, due to fatty de-
tension, scoparius yields good results ; position around the heart, sparteine
also in the edema, or dropsy, accom- is satisfactory. In dilatation due to
panying heart lesions. It is con- valvular disease sparteine may be
traindicated in the acute stage of given hypodermically. In functional
inflammation of the lungs, heart, or cardiac disease, the result of exces-
kidneys, but in the subacute or sive bodily or mental labor, anxiety,
chronic stage it may be used w^ith and in "tobacco heart," sparteine will
advantage. In hydrothorax and as- yield gratifying results. In chronic
cites occasional doses of compound parenchymatous nephritis sparteine
jalap powder may be combined with will aid in the elimination of urea
it to advantage. and thus prevent uremia. In valvular
Scoparin has been used as a diu- cardiac disease, due to acute articular
retic in doses of from 8 to 15 grains rheumatism, cardiac dilatation with
(0.5 to 1 Gm.) by the mouth, or ^ failing compensation, chorea asso-
to 1 grain (0.03 to 0.06 Gm.) dis- ciated with endocarditis, exophthal-
8—7
98 SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
mic goiter, etc., Cerna has obtained scopola (or scopolia) is derived from
good results from the use of si)ar- Scopoli, an Italian who was professor
teine. In morphine addictions spar- of botany in Pavia about the middle
teine is useful in supporting the heart of the eighteenth centur}^
and system during the withdrawal of Though discovered, the one in hyo-
the drug. In postoperative suppres- scyamus and the other in scopola,
sion of urine, postanesthetic nausea, hyoscine and scopolamine are identi-
and operative shock, Pettey places cal chemically. Most of the drug be-
great faith in sparteine, but insists ing obtained from scopola rather than
that the dose be at least 2 grains hyoscyamus, the term scopolamine is
(0.13 Gm.), repeated every two to six often given preference, and in many
hours, when the effect of the remedy European countries it is the only
is to be assured. Hysterical excite- appellation used.
ment is, in many cases, amenable to Officially, that is to say, from the
sparteine sulphate. standpoint of the United States
C. Sumner Witherstine, Pharmacopoeia, scopolamine and hyo-
Philadelphia. seine are identical in all respects. A
slight distinction is, however, some-
SCOPOLAMINE (HYOSCINE) times made between the two sub-
AND SCOPOLA. — Scopolamine, or stances with respect to their optical
hyoscine (C17H21NO4), is an alkaloid properties, scopolamine being taken
obtained from various plants of the to refer to a completely levorotatory
family Solanacese, including Atropa specimen of the alkaloid, i.e., one
belladonna, Datura straniomum, Hyo- which rotates the plane of polarized
scyamus nigcr, and Scopola carniolica. light as far to the left as this par-
The last-named plant is an herb ticular chemical compound is capable
growing in the eastern Alps, Car- of doing it, and is composed exclu-
pathian Alountains, and neighboring sively of levorotatory molecules,
regions, and contains about 0.6 per while hyoscine is taken to refer to
cent, of total mydriatic alkaloids, in- any specimen ranging between the
eluding 0.06 per cent, of scopolamine, completely levorotatory and the in-
Scopola japonicas is another species of active, the latter being a mixture in
the plant, growing in Japan, and con- equal parts of levorotatory and dex-
taining the same principles as the trorotatory molecules. The optically
European scopola. In these two inactive variety of hyoscine is termed
plants, scopolamine is present in atroscine. Levoscopolamine, imder
larger amount than in the other mem- the influence of light, is gradually
bers of the solanaceous group, the transformed into atroscine, thereby
next being hyoscyamus, which, in its suft'ering some reduction in its pcriph-
total alkaloidal content of 0.08 to 0.15 eral nervous effects, i.e., mydriasis,
per cent., contains 0.02 to 0.0375 per vagal paralysis, arrest of secretion,
cent, of scopolamine (Kraemer). The etc. For ordinary purposes, however,
histological structure of the scopola scopolamine and hyoscine are gener-
rhizome, which is the part of the plant ally considered equivalent. Various
used in medicine, closely resembles preparations that have, in the past,
that of belladonna root. The name been termed hyoscine have consisted
. SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 99
merely of a more or less impure ally administered hypodermically,
scopolamine. though oral use is also feasible, the
PREPARATIONS AND DOSE, alkaloids being absorbed with almost
— Scopolamincc hydrobromidnm, U. S. equal certainty, though less rapidly,
P. (scopolamine or hyoscine hydrobro- than when injected. Solutions of the
mide) [Ci7HoiN40.HBr-)-3H20], oc- alkaloids deteriorate quickly on keep-
curring in colorless rhombic crystals, ing, but Straub has found that by
sometimes of large size, with an acrid, adding to them 5 to 20 per cent, of
slightly bitter taste, and slightly efflores- mannite — a harmless substance which
cent. It is soluble in 1.5 parts of may be injected into the tissues with-
water, in 16 parts of alcohol, and in out fear of causing local irritation —
750 parts of chloroform. It should be they may be kept for an indefinite
kept in amber-colored vials. Dose, ^^o period without loss of activity,
to i/so grain (0.0002 to 0.001 Gm.). PHYSIOLOGICAL ACTION.—
The following preparations were for- Nervous System. — Scopolamine (hyo-
merl}^ official: — seine), like atropine, produces distinct
Scopola, U. S. P. VIII (scopola), effects on both central and peripheral
the dried rhizome of Scopola carnioHca, nervous structures. Its central ef-
required to yield not less than 0.5 per fects differ in quality, however, from
cent, of mydriatic alkaloids. Dose, j/i those of atropine, consisting chiefly of
grain (0.045 Gm.). a pronounced depression of the psy-
Fluidcxtractiim scopolcc, U. S. P. chic and motor centers of the brain,
VIII (fluidextract of scopola), contain- the result being a hypnotic effect,
ing 0.5 Gm. of mydriatic alkaloids in which passes, if the dose be large
each 100 c.c. Dose, 1 minim (0.06 c.c). enough, into narcosis. The electrical
Extractum scopolcc, U. S. P. VIII excitability of the brain is reduced,
(extract of scopola), made by evap- The human subject to whom scopola-
orating the fluidextract, and required mine (hyoscine) has been adminis-
to contain 2 per cent, of alkaloids, tered becomes quiet and sluggish.
Dose, % grain (0.01 Gm.). because of early depression of the
Hyoscincc hydrobromiduni, U. S. P. motor centers, and soon falls asleep.
VIII (hyoscine hydrobromide), chem- At times these effects appear, after a
ically identical with scopolamine hydro- short period of latency, with marked
bromide. Same dose. suddenness, and their intensity may
INCOMPATIBILITIES. — Hyo- prove alarming to nearby persons,
seine and scopolamine are incom- Occasionally sleep is preceded by a
patible with alkalies, tannic acid, short period of excitement, which
potassium permanganate, iodides, and may either represent an attenuated
salts of some of the heavy metals, manifestation in scopolamine of the
such as mercury bichloride, silver delirifacient action of atropine or be
nitrate, lead acetate, and ferric due to the presence of the convulsive,
chloride. highly toxic alkaloid apoatropine as
MODES OF ADMINISTRA- an impurity. (This impurity may be
TION. — Scopola, when used, is ad- detected by adding a little dilute
ministered by mouth. The alkaloids potassium permanganate solution to
scopolamine and hyoscine are gener- the solution of scopolamine, the violet
100 SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
color changing- to a yellow-brown if Respiration. — The effect on the re-
apoatropine is present.) In excessive spiratory is the same as that on the
amounts scopolamine induces either vasomotco" center. Respiration is de-
coma or — probably only if impure — a pressed by full doses,
condition of sleep and unconscious- Eye. — Scopolamine, instilled in the
ness interrupted at more or less fre- eye, acts like atropine, but more
quent intervals with a delirious rapidly and in an amount about four
outburst or low, muttering delirium, times less. A 0.2 per cent. (1 grain
Scopolamine acts upon the spinal cord to the ounce) solution will dilate the
as on the brain, a more or less com- pupil in ten to thirty minutes, and
plete depression of the spinal reflexes shortly thereafter induce paralysis of
being, therefore, characteristic, espe- accommodation. These effects are
cially after large doses. due to paralysis of the oculomotor
The peripheral nervous effects of nerve endings in the constrictor mus-
scopolamine are essentially those of cle of the iris and the ciliary muscle,
atropine, consisting of depression or respectively. The drug does not in-
paralysis of the terminals of the vago- crease intraocular tension. Its effects
sacral autonomic system and of the on the eye pass off more rapidly than
secretory nerves. The effects of atro- those of atropine, viz., in three to five
pine on the pupils, involuntary mus- days. The pupil regains its normal
cles in general, and secretions are diameter in about seventy hours, and
reproduced, though the dosage of the power of accommodation is re-
scopolamine for simple hypnotic pur- covered in four days (Oliver). A
poses being, as a rule, less than the slight stinging or feeling of astrin-
customary full dose of atropine, these gency in the conjunctiva may be ex-
effects are not as often noticed as perienced after its instillation,
w^ith atropine. Although the ability Secretions. — Scopolamine inhibits,
of scopolamine to paralyze the end- like atropine, those secretions which
ings of the vagus nerves in the heart, are under nervous control, paralyzing
and therefore to accelerate heart ac- the endings of the secretory nerves
tion is not questioned, many have distributed to them. Kamensky wit-
clinically noticed slowing of the heart nessed arrest of the salivary, gastric,
after its administration. This is pancreatic, and sweat secretions by
doubtless either an indirect eft'ect. the drug in laboratory animals; the
the result of motor inactivity, or effect on the pancreas took place
due to admixture of some cardiotoxic much later than that on the other
impurity. secretions.
Circulation.— Or d\n2ir\\y no cardiac ABSORPTION AND ELIMINA-
acceleration is induced by scopola- TION. — Scopolamine is readily ab-
mine, the dose used being too small, sorbed from mucous membranes. It
The alkaloid differs from atropine, in is more rapidly destroyed in the sys-
that it has no stimulating effect on tern or excreted than atropine, and
the vasomotor center. In large doses, its eff'ects are of correspondingly
it depresses this center from the shorter duration.
start, a corresponding reduction in UNTOWARD EFFECTS AND
the blood-pressure taking place. POISONING. — The dose of scopola-
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
101
mine borne without unpleasant re-
sulting symptoms seems to vary
considerably in different individuals.
Occasionally somnolence and dizzi-
ness appear in ophthalmic use of the
drug". In persons with an idiosyn-
crasy therapeutic doses may. in addi-
tion, produce effects similar to those
of beginning atropine intoxication,
viz., dryness of the mouth, flushing
of the skin, mydriasis, and difficulty
in swallowing. The dose ordinarily
toxic lies between ^Xoo and Yso grain
(0.0006 and 0.002 Gm.). From doses
larger than are required for thera-
peutic effects there result, in addition
to the symptoms already mentioned,
ataxia, indistinct speech, unconscious-
ness, perhaps followed by delirium
and hallucinations and an accelerated
feeble pulse.
Even therapeutic amounts at times
produce alarming effects. Thus, cases
of collapse from ^,,0 grain (0.0006
Gm.) have been reported, with pro-
nounced muscular weakness, flushing
of the face, a hard, rapid pulse, noisy,
rapid breathing, twitching of the
hands, and cool perspiration. Col-
lapse has also been recorded from
ophthalmic instillation of the drug.
M. L. Foster has reported the case of
a young man in whom four instilla-
tions of 1 drop of a 0.2 per cent, solu-
tion of scopolamine hydrobromide
had been made in each eye at ten-
minute intervals — total amount about
Yqo grain (0.001 Gm.). Fifteen min-
utes after the last instillations dizzi-
ness appeared, followed by dryness of
the throat, nausea and attempts to
vomit, flushing of the face, motor
weakness, and tachycardia (over 160
a minute), attaining their maximum in
about two hours ; the patient became
cyanotic, actively delirious, and had
what appeared to be toxic convul-
sions. Rapid recovery thereafter took
place under morphine and whisky.
S. W. Morton has recorded a case of
poisoning by Y-, grain (0.0008 Gm.)
of hyoscine hydrobromide, with in-
ability to swallow and complete pa-
ralysis of the soft palate and upper lip.
In an ataxic man Gibbs witnessed
poisoning, with delirum and convul-
sions, from y^Q grain (0.0012 Gm.).
R. A. Morton, after instillation of 2
drops of 1 per cent, hyoscine hydro-
bromide into the eyes of an adult,
observed muscular relaxation and un-
consciousness lasting four hours, fol-
lowed by delirium lasting two hours,
and then sleep lasting one and one-
half hours. F. Krauss observed excite-
ment lasting over seven hours in a
girl of 15, who had instilled 2 drops
of a 2-grain to the ounce solution in
each eye before retiring.
Fatal results from scopolamine in-
toxication have been rare. Bastedo
has met with fatal collapse from %o
grain (0.0012 Gm.) in an alcoholic
man with pneumonia. On the other
hand, he witnessed recovery from ^5
grain (0.0024 Gm.) in an alcoholic
woman verging on delirium tremens.
In each of these cases morphine had
preceded the hyoscine. Recoveries
from ^ and even 3^ grain (0.03 Gm.)
of hyoscine in cases subsequently re-
ceiving more or less therapeutic at-
tention have been reported.
Treatment of Poisoning. — If the
drug has been taken by the mouth,
the stomach should be evacuated with
emetics or the stomach-tube. Tannic
acid or Lugol's solution may precede
this, if they are immediately at hand
and the case is seen early. As
physiological antidotes, pilocarpine,
J4 grain (0.015 Gm.), and strychnine,
102
SCOPOLAMINE (HVOSCINE) AND SCOPOLA (SAJOUS).
Vso to 1/20 grain (0.002 to 0.003 Gm.),
or caffeine sodiobenzoate, 5 grains
(0.3 Gm.), or hot, strong coffee
should be given. Where delirium re-
places the unconsciousness or coma,
sedatives such as chloral hydrate, 10
grains (0.6 Gm.) ; tincture of opium,
15 minims (1 c.c), or morphine, %
grain (0.01 Gm.) hypodermically, may
be availed of. Electricity and other
excitants of the skin surface may be
used, as in opium poisoning, to com-
bat narcosis. In cases with pro-
nounced circulatory depression, digi-
talis, epinephrin, ether, ammonia
preparations, etc., should be freely
used. Artificial respiration, external
heat, skin frictions, and oxygen in-
halations are other measures that
may prove of value.
THERAPEUTICS as Sedative to
the Central Nervous System. — In in-
somnia due to mental excitement, a
persistent wandering of the mind
from one subject of thought to an-
other preventing sleep, and in the
insomnia of neurasthenia, scopola-
mine (hyoscine) in small doses, such
as %oo grain (0.0002 Gm.), is of value
where other milder hypnotics fail or
have to be discontinued because of a
tendency to habit formation. Though
less certain in its effect than chloral
hydrate, scopolamine has advantages
over the latter in being of small bulk,
non-irritating, and well suited for
hypodermic use. According to Wind-
scheid, as little as %5o grain (0.0001
Gm.) is capable of causing somno-
lence. In sleeplessness due to pain,
scopolamine is ineffectual when given
alone, but if combined with morphine
in small amounts proves useful, in-
tensifying the action of the latter.
In the insomnia due to motor ex-
citation, scopolamine is particularly
effective. This applies in delirum
tremens, in which, e.g., Lambert
recommends a combination of sco-
polamine hydrobromide, ^/|oo grain
(0.0006 Gm.), with apom^orphine hy-
drochloride, %o grain (0.003 Gm.),
and strychnine sulphate, fvQ gram
(0.002 Gm.), administered hypoderm-
ically. Liepelt found it more active
in this condition, if properly applied,
than either chloral hydrate or mor-
phine. In the delirium of infectious
diseases, including pneumonia, ty-
phoid fever, septicemir, etc., scopola-
mine is of value, especially where a
feeble, dilated heart or pronounced
circulatory impairment, e.g., in alco-
holics, contraindicate the use of
chloral hydrate. For this purpose it
should be used in moderate dosage —
yi50 to 1/100 grain (0.0004 to 0.0006
Gm.). If the first dose proves totally
ineffective, or the delirium, as oc-
casionally happens, is increased in-
stead of diminished, the drug should
not be further used. Similar consid-
erations apply in the insomnia of
infectious diseases. In pronounced
restlessness in neurasthenia, scopo-
lamine may also be used with
advantage.
In acute maniacal states the use
of scopolamine has, to a considerable
extent, replaced that of morphine.
According to H. S. Noble, in the re-
curring forms of insanity, maniacal
attacks can often be averted with it.
Such patients, at the first intimation
of approaching excitement, are given
an active cathartic, usually mercurial,
followed by 1/100 to 1/75 grain (0.0006
to 0.0008 Gm.) of scopolamine hydro-
bromide morning and evening, rarely
oftener. Little or no tolerance to the
drug is established. In agitated
melancholia Doerner found scopola-
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 103
mine often to bring about quietude scopolamine, given half an hour be-
when all other means had failed. The fore retiring, of great value in
effect comes on rapidly and lasts from controlling the spasmodic cramps
three to ten hours, according to the sometimes experienced in the lower
dose given. Insane patients are often extremities on retiring, or upon
more resistant to the effects of sco- stretching in the morning. The same
polamine than others, doses of %4 author successfully employed ^^s
grain (0.001 Gm.), or even more, be- grain (0.0008 Gm.) at night to arrest
ing sometimes necessary ; on the excessive seminal emissions. Higier
other hand, doses as small as ^-jO found the drug valuable in pruritus
grain (0.00025 Gm.) are sufficient in of all kinds, except diabetic. It has
some instances. The absence of un- also been used with benefit in
pleasant after-effects is a marked ad- hiccough.
vantage of this drug. In the tremor of paralysis agitans
Among other nervous conditions in and in senile or alcoholic tremor,
which scopolamine may be availed of scopolamine yields prompt, though
are status epilepticus, chorea, hyster- not always lasting, effects. It may
ical convulsions, and the convulsions be used in daily doses of %4o to /42o
of cerebrospinal meningitis. Higier, grain (0.00025 to 0.0005 Gm.), hypo-
in a case of obstinate chorea occur- dermically, in these conditions, and
ring in pregnancy, was able to control may be given for a long period with-
the movements by giving a %o-grain out habituation or detrimental effect.
(0.001 Gm.) dose daily for a week. It has also been recommended in
In nervous asthma, the same author multiple sclerosis.
had good results from the adminis- In the night-sweats of pulmonary
tration of %5o to %25 grain (0.00025 tuberculosis and in lead colic scopo-
to 0.0005 Gm.) subcutaneously at the lamine has also been used, with
time of the attack, together with j^artial success.
smaller doses during the intervals as For its use during withdrawal of
prophylactic. In attacks of hystero- morphine from habitues, the reader is
epilepsy Nagy usually obtained seda- referred to the article on Opium
tion in five to twenty minutes by Habit.
means of an injection of %4 grain As Mydriatic and Cycloplegic. —
(0.001 Gm.) of the drug. In tri- For refraction purposes scopolamine
geminal neuralgia with attacks of presents certain advantages over atro-
muscular contracture, Pont procured pine, and is even preferred to the
relief of pain and diminished fre- latter for routine use by some spe-
quency and duration of the attacks cialists. Two instillations of a drop
of contracture by giving daily injec- each of a 1-grain (0.06 Gm.) to the
tions, either into the cheek at the ounce (30 c.c.) solution of scopola-
painful spot or into the arm, of %-2o mine hydrobromide at an interval of
grain (0.0002 Gm.) of scopolamine half an hour are sufficient to produce
hydrobromide, four days' treatment complete mydriasis and cycloplegia
being alternated with rest periods of in less than an hour after the first in-
equal duration. Noble found ''/120 to stillation. Even a 1 in 1000 solution
Yioo grain (0.0005 to 0.0006 Gm.) of is usually sufficient, especially if the
104
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
patient is required to instill it on the
evening- before and the morning' of
the day of consultation. The myd-
riasis and likewise the paralysis of
accommodation pass off, according to
the amount of drug used, individual
sensitiveness, etc., in from two to
four days, thus markedly shortening
the period of disability experienced as
compared to atropine. Pressure over
the lower canaliculus after instillation
is recommended to minimize the pos-
sibility of constitutional effects by
preventing drainage of the drug into
the lachrymal passages and nasal
cavities, whence it is more rapidly
absorbed.
In inflammatory infections of the
eye, scopolamine is held to be equally
as valuable, or more valuable, than
atropine, and it is said not to increase
intraocular tension. In rheumatic or
syphilitic iritis, it may be combined
with or substituted for atropine in
instillations, and may also, with ad-
vantage, be given hypodermically at
night to relieve pain. In plastic iritis
scopolamine acts very energetically,
often removing synechise, which atro-
pine had failed to influence (Raehl-
mann). In uveitis (serous cyclitis),
scopolamine may be used in the ab-
sence of increased intraocular tension
(De Schweinitz). It may also be
substituted for atropine in sympa-
thetic ophthalmitis.
MORPHINE-SCOPOLAMINE
ANESTHESIA.— The first report on
anesthesia produced by a combina-
tion of morphine with scopolamine
was made in 1900 by Schneiderlin, an
alienist, who, having used the drugs
simultaneously for sedative purposes
in restless, insane patients, with sat-
isfactory results, proceeded to employ
them to induce surgical anesthesia in
demented cases. The procedure is
based chiefly on synergistic action of
the two drug's as narcotics. Although
the antagonism between them in cer-
tain of their other effects might be
thought of marked advantage, per-
mitting the use of large doses with
the exclusive view of causing narcosis
and eliminating apprehension of un-
pleasant side effects, this is true only
to a slight degree, the opposite effects
of the drugs on the pupil and heart
rate having but little value, except as
indications of the relative degree of
action of the drugs in the individual
case.
The experiences of Terrier, E. Ries,
A. C. Wood, W. Wayne Babcock,
and others, have shown that by sub-
cutaneous injection of scopolamine
and morphine alone, without any in-
halation anesthetic, a satisfactory
surgical anesthesia can, in many
instances, be obtained. This is es-
pecially the case in the aged, debili-
tated, and cachectic. The young- and
robust, on the other hand, are re-
sistant and show a tendency to
excitement and delirium under scopo-
lamine, which largely unfits them for
this form of anesthesia. Babcock,
substituting in young adults, for mor-
phine and scopolamine (or adding to
them) apomorphine, or an enema
containing Hoffman's anodyne, alco-
hol, and sometimes paraldehyde, has
found that one may produce general
anesthesia in most persons over 18
years of age without resort to in-
halation of ether or chloroform. The
procedure proved very satisfactory —
often giving results superior to any
other form of anesthesia — in opera-
tions upon the head, neck, respiratory
system, and spinal column. In ab-
dominal and rectal operations, on the
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 105
other hand, and to some extent in of the inhalation anesthetic, respira-
operations on the hands and feet, it tion is quiet and regular, and during
was found inferior owing to failure the operation there is no vomiting or
to abolish muscular rigidity and obstruction to breathing from fluid in
reflexes. the air-passages. While the pulse
Morphine-Scopolamine Preliminary may be accelerated by the scopola-
to Inhalation Anesthesia. — In spite of mine, its quality remains good. The
the numerous advantages of exclusive patient is able, where the part oper-
narcotic anesthesia, where applicable, ated upon permits, to take water or
the procedure is, in general, accorded even food shortly after awakening
only a small field of application be- without nausea or vomiting. The
cause of the special care required to procedure is especially valuable in
avoid serious respiratory depression — neurotic subjects, and in patients with
both during and for some time after organic disease of the respiratory
the operation by the narcotics given — tract. A much larger dosage is re-
especially the morphine, and the rela- quired in alcoholic, strong men than
tively high mortality which has fol- in aged persons, and in the female
lowed its application in unskilled sex.
hands. Injection of morphine and According to Biirgi, substitution of
scopolamine in smaller amounts be- pantopon (omnopon) for the mor-
fore anesthesia by ether or chloro- phine in the morphine-scopolamine
form, on the other hand, is considered combination is of advantage, in that
less dangerous and looked upon with the respiratory center is less influ-
much more favor. The dosage ranges enced and the likelihood of vomiting,
from % grain (0.01 Gm.) of morphine A %-grain (0.04 Gm.) dose of panto-
and K20 grain (0.0005 Gm.) of scopo- pon, with 1/1.50 to 34oo grain (0.0004
lamine to twice these amounts, given to 0.0006 Gm.) of scopolamine is held
either in one dose one-half to two to be without danger in strong in-
hours before the time of operation or dividuals of middle age, though in
in divided doses. In small-sized pa- delicate or old persons with respira-
tients, doses somewhat less than tory disturbances the dose of pan-
those mentioned may be given, e.g., topon should be considerably less.
% grain (0.008 Gm.) of morphine Reichel and Keim, on the other hand,
and ^.rjo grain (0.0004 Gm.) of specifically mention respiratory de-
scopolamine. pression as a possibility in the use of
The procedure is advantageous in pantopon. Reichel much prefers to
many ways, allaying the patient's ap- substitute for the latter narcophine, a
prehension, diminishing after-pain by meconic acid compound of morphine
lengthening the period of narcosis, and narcotine. Keim has found thirst
and distinctly lessening postanesthe- a troublesome symptom after panto-
tic vomiting. The inhalation an- pon-scopolamine anesthesia,
esthetic is taken quietly, rapidly, and Morphine-Scopolamine Preliminary
without struggling, little or no secre- to Local and Spinal Analgesia. —
tion in the mouth and respiratory In local and spinal types of analgesia
tract takes place, anesthesia is main- the patient remains alert and appre-
tained with a very small expenditure hensive, and at times has trouble,
106 SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS).
especially under local analg"esia, in any pain, or at least, if pain is ex-
keeping- himself under control. To perienced, recollection of it after the
overcome this difficulty and facilitate operation is completely or largely
the surgeon's work, as well as in local 1)lotted out.
analgesia, which is frequently incom- Morphine-Scopolamine in Obstet-
plete, to reduce the shock to the rics. — The combination of morphine
nervous system from tissue injury by and scopolamine was first employed
dulling the sensibility of the sensory in obstetrics in 1903 by Steinbuchel,
centers, morphine and scopolamine merely to reduce the pain attending
may be employed to great advantage, labor, without producing any degree
W. Wayne Babcock usually orders of narcosis. The procedure definitely
administered, one hour and a quarter intended not only to reduce suffering,
before the induction of spinal anes- but also to banish the memory of
thesia, % grain (0.01 Gm.) of mor- pain after the completion of labor
phine sulphate and Vioo grain (0.0006 was, however, elaborated by C. J.
Gm.) of scopolamine hydrobromide. Gauss, of Kronig-'s clinic in Freiburg,
Where, shortly after, the patient is who in 1907 reported 1000 cases in
not in a condition of distinct drowsi- which this method had been success-
ness (though still showing some re- fully applied. In the following year
sponse when spoken to), an additional Kronig reported a series of 15O0
dose of each remedy is given twenty cases, in which one child had died
minutes after the first. If, as is the during delivery and three others in
case in a few instances, the effect is the first three days after delivery,
still insufficient, a third dose is given. Thereafter it was not until . a more
sometimes of only one of the drugs, recent favorable report of 5000 cases
stress being laid rather on the mor- liad been made by Gauss that wide-
phine in young and on the scopola- spread interest in the method was
mine in older subjects. Before major reawakened.
operations under local anesthesia, in The price of success and relative
which a deeper soporific effect is, in safety in the use of this procedure is
general, of advantage, Babcock sup- held by many to be a rigid adherence
plements the morphine-scopolamine to the somewhat complex and pains-
administration with a narcotic enema requiring original method of Gauss,
consisting of Hoffman's anodyne who, in the process of obtaining a
(Spiritus setheris compositus, U.S. P.), simple state of amnesia with partial
^ to 1 fluidounce (15 to 30 c .c.) ; insensibility to pain, — the so-called
paraldehyde, 2 fluidrams to Yi fluid- twilight sleep (Dammerschlaf), —
ounce (8 to 15 c.c), and water, 5 carefully adjusts the dosage to the
fluidounces (150 c.c). At the con- individual case by means of a
elusion of the operation 2 quarts (lit- "memory test" carried out at inter-
ers) of normal saline solution are vals during the course of labor. In
introduced in the bowel to accelerate primiparse, the first sedative injection
elimination of the narcotics. By these is given when good uterine contrac-
means the patient operated under tions are taking place every four or
local anesthesia passes through the five minutes and persisting at least
operation without being conscious of one-half minute. This injection con-
SCOPOLAMINE (HYOSCINE) AND SCOPOLA (SAJOUS). 107
sists of 0.01 Gm. (% grain) of mor- Gm. (Yi^o grain). This is followed
phine hydrochloride, and 0.00045 Gm. in three-quarters of an hour by 0.0003
(%40 grain) of scopolamine hydro- Gm. (^/2oo grain) of scopolamine
bromide, injected separately into the alone, and in three-quarters of an
buttock or thigh. Three-quarters of hour more by narcophine, 0.015 Gm.
an hour later, the same dose of sco- (>^ grain), and scopolamine, 0.00015
polamine is repeated alone. One-half Gm. (^/4oo grain). The sedative ac-
hour after, a memory test is used, the tion is thereafter maintained by re-
patient being asked how many injec- peating the scopolamine in 0.00015
tions she has had, and if she remem- Gm. (i/4oo grain) doses every two
bers some strange object, such as a hours. Repetition of the narcophine
drinking-cup, exhibited to her at the is seldom required, though it may be
time of the first injection. The mem- given at six-hour intervals in a pro-
ory test is repeated thereafter, using longed labor.
new objects each time, every half- Opinions as to the value of mor-
hour, and if memory is still present phine or narcophine-scopolamine ad-
one and a half hours after the second ministration in obstetrics vary from
injection a third injection of scopo- enthusiastic advocacy of the measure
lamine, 0.0003 Gm. {Y200 grain) only, as a routine procedure — barring cer-
is given. Subsequent memory tests tain definite contraindications — to
may indicate additional injections of complete condemnation. B. C. Hirst
scopolamine, but these should be summarizes the disadvantages of the
small, and given only at long inter- method as "prolongation of labor,
vals. No additional morphine is ad- tendency to atony of the uterus with
ministered after the first dose. To hemorrhage, and an increased propor-
permit the development of a proper tion of apneic babies that could not
"twilight sleep," absolute quiet and be revived." With minimum doses
plugging of the patient's ears and of the two drugs these disadvantages
covering of her eyes are of impor- disappeared, but the relief afforded
tance. The maternal pulse, pupil re- was scarcely noticeable. He found
flexes, and temperature, as well as the the method of value, however, chiefly
fetal heart rate, are to be taken every for its psychic effect, in neurotic
half-hour so quietly that the patient's primiparse in whom a long, painful
state of sopor will not be disturbed. labor is considered probable. J. C.
In order to increase the field of Applegate noted very satisfactory re-
availability of the method, Siegel has suits in a small percentage of cases,
elaborated a modified Gauss technique but accords the method only a limited
in which the attempt to individualize field in obstetrics. Polak, on the
the dosage is abandoned, a standard other hand, has reported a series of
routine dosage being prescribed, and 155 cases with but three failures, no
no memory tests used. When labor fetal mortality, and no post-partum
is definitely established, the first in- hemorrhage. He asserts that nar-
jection is given, consisting of narco- cotization of the child (beyond
phine (morphine and narcotine me- oligopnea for a few minutes), if en-
conate), 0.03 Gm. ()^ grain), and countered, is not the fault of the
scopolamine hydrobromide, 0.00045 method, but of the dosage and man-
108
SCORBUTUS.
ner of applying- it, and that the actual
fetal mortality is lessened, rather
than increased, by the procedure. In
prirnipar?e of the physically unfit type,
commonly becoming exhausted at the
end of the first stage of labor, the
method brings necessary rest be-
tween contractions, obviates ex-
haustion, and greatly reduces the
proportion of cases requiring high or
medium forceps application. In bor-
der-line disproportion cases, if opera-
tive delivery becomes necessary, this
can be done with less shock and less
general anesthesia. In cardiac and
tuberculous cases, Polak uses the
method to reduce the strain placed on
the circulation in the first stage of
labor. Contraindications to its use
are emergency conditions, such as
precipitate labor, placenta previa, ac-
cidental hemorrhage, eclampsia, pro-
lapse of the cord, primary inertia, and
a dead fetus. The procedure may be
applied, however, in the first stage
to secure dilatation in malpositions,
scopolamine, properly used, having
been shown to favor dilatation of
the cervix and reduce uterine spas-
ticity. It does not diminish mam-
mary secretion.
L. T. DE M. Sajous,
Philadelphia.
SCORBUTUS.— Scorbutus, or scur-
vy, is a constitutional disorder, dependent
upon a deficiency of vegetable food, and
characterized by a peculiar form of
anemia, great mental and bodily prostra-
tion, spongy gums, a tendency to the
occurrence of mucocutaneous and sub-
periosteal Hemorrhages, and a brawny
induration of the muscles, especially those
of the calves and the flexor muscles of
the thighs.
Scorbutus has almost totally disap-
peared owing to the wise laws enacted
by the various maritime countries, based
on the discovery that deprivation of certain
substances present in fresh fruit and vege-
tables is the tmderlying cause.
SYMPTOMS.— The early symptoms of
scorbutus are a rapidly progressive ane-
mia, the surface becoming dirty-looking,
sallow, pallid, or earthy in appearance; a
gradually increasing de))ility, emaciation,
and indisposition for bodily and mental
exertion; arthritic and muscular rheu-
matoid pains in the limbs and back; men-
tal apathy or depression; dyspnea upon
slight exertion; the tongue may continue
clean, but it becomes large, pale, flabby,
and indented by the teeth. The appetite
usually remains good. The bowels, as a
rule, are constipated.
Other manifestations now appear. Pe-
techial spots arranged about the hair-fol-
licles are observed, first on the lower
extremities, later on other parts of the
skin surface. These spots are followed
by large subcutaneous extravasations and
puffy swellings in various parts of the
body, apparently due to deep-seated co-
pious hemorrhages, as, later, the surface
over them becomes ecchymotic. These
swellings chiefly occupy the popliteal
spaces, the anterior aspects of the elbows
and of the lower part of the legs, the
space behind the angles of the jaw, and
the loose connective tissue in and about
the eyelids, giving them a puffy, bruised-
like appearance, and often accompanied by
a sanguineous accumulation in the sub-
conjunctival tissue covering the eyeball.
The gums now begin to swell, especially
at the edges, become spongy and lobu-
lated, rising sometimes above the teeth
and concealing them. They are deep-red
or livid in color, bleed easily, ulcerate or
slough, and give rise to an exceedingly
fetid odor. The teeth often become loose
and, in exceptional cases, drop out. A
tendency to ulceration or sloughing be-
comes more or less general in all parts
of the cutaneous surface, more especially
at the locations of the puffy swellings, be-
ing easily induced by a slight scratch,
pressure, or blow.
The anemia increases. The face be-
comes puffy and anasarca, more or less
marked, appears in the lower extremities;
dyspnea develops; the heart-action be-
comes feeble and irregular, and the pulse
small, soft, and, on exertion, much ac-
SCORBUTUS.
109
celerated. The slightest exertion excites
attacks of sudden syncope, which may be
fatal.
Late in the disease the appetite is apt
to fail; the bowels become loose, the
stools being usually very ofifensive, and,
not infrequently, containing blood; nerv-
ous symptoms are now manifest; visual
disorders, including hemeralopia and nyc-
talopia, tinnitus aurium, vertigo, insomnia,
and late delirium may be present; menin-
geal hemorrhage may occur. The intellect
usually remains unaffected.
During the progress of the disease
thoracic complications maj^ appear, such
as pleurisy with effusion (often bloody),
pulmonary congestion with extravasation
of blood into the lung-tissue, bronchial
congestion, cough, and blood-stained sputa,
having, not infrequently, a gangrenous
odor.
The urinary symptoms vary. Albumi-
nuria is not rare. The specific gravity of
the urine is increased, the color high, the
solids diminished, excepting the phos-
phates, which are usually larger in amount.
Nephritis may occur.
The bones in chronic cases may become
congested, or even necrotic, and the epi-
phyces separate from the shafts.
The duration of scurvy may be several
weeks or months. Death commonly re-
sults from sudden syncope or from grad-
ual asthenia, hastened, in some cases, by
the occurrence of ulceration, hemorrhage,
thoracic affections, or other complications.
DIAGNOSIS.— The diagnosis is made
from the history, the peculiar facies, the
spongy and swollen gums, the gingival
and deep-seated cutaneous hemorrhages,
the increasing loss of strength and energy,
the mental depression, and the rapid re-
sponse to correct treatment.
From purpura hemorrhagica it is dis-
tinguished by its chief causative factor —
a diet lacking in fresh vegetables and
fruits — by the spongy, swollen gums,
loosened teeth, and the brawny induration
of the limbs. In purpura hemorrhagica,
the ecchymotic spots are not arranged
around a hair-follicle, and the hemor-
rhages from the mucous membranes are
greater in amount.
ETIOLOGY. — Tn former times scorbu-
tus was prevalent among sailors on pro-
longed voyages, in armies in active service,
and among people suffering from famine.
According to Osier, the disease is not in-
frequent among the Hungarian, Italian,
■ and Bohemian miners in Pennsylvania. It
is rarely epidemic. It is, however, en-
demic, especially in parts of Russia (Hoff-
man) and elsewhere, sweeping through
prisons, barracks, almshouses, and institu-
tions of like character.
The chief predisposing cause is a long-
continued dietary, lacking in certain essential
but obscure substances found in fruits and
fresh vegetables. Unhygienic surround-
ings, excessive muscular exercise, humid-
ity, cold, and other debilitating influences
are recognized as etiological factors. Testi
and Beri have isolated a micro-organism
which the}' believe to be pathogenic.
PATHOLOGY.— The pathology of scor-
butus corresponds to the symptoms. Mi-
croscopic examination of the blood reveals
the presence of profound anemia; the
blood is of low specific gravity, thin and
dark, contains an excess of fibrin, less
hemoglobin, and fewer red blood-cells,
but there is no leucocytosis. The skin
may be the seat of ecchymoses (subcu-
taneous hemorrhages), but the most char-
acteristic hemorrhage is that under the
periosteum of the femora. Extravasations
of blood, in various stages of transforma-
tion, may also be found in the lung-sub-
stance, beneath the pleurae, in the heart-
muscle, in the subpericardial tissue, in the
intestinal parietes, and beneath the peri-
toneal membrane. Blood-stained serum
may be found in the various serous cavi-
ties. The internal organs ma}-, or may
not, be congested. The brain is usually
intact. The heart, liver, and kidneys are,
occasionally, the seat of parenchymatous
or fatty degeneration.
PROGNOSIS.— If the disease has not
progressed too far and appropriate treat-
ment is available, the prognosis is good;
otherwise, the outlook is grave. The in-
ternal symptoms, especially the pulmo-
nary, are more serious than the external
ones. Pneumonia, hemorrhagic infarct of
the lung, pleurisy with bloody effusion,
acute nephritis, or dysentery, is usually
followed by death.
TREATMENT.— Prophylaxis demands
an adequate supply of antiscorbutic food
110
SEASICKNESS (WITHERSTINE).
for long seavoyagcs, military campaign-
ers, and explorers in the frozen zones.
This is facilitated by the present-day abun-
dance of canned fruits and vegetables,
though canning may reduce their value.
In the treatment of the disease the two
indications are to provide a diet of citrus
fruits and of vegetables containing the
necessary antiscorbutic vitamincs or salts,
and to combat special symptoms and com-
plications. The use of the juice of two
or three lemons or oranges daily will be
followed by marked improvement.
If the digestion is feeble give orange- or
lemon- juice combined with meat-juice or
egg-album.in, milk and farinaceous foods.
When the condition improves, the stronger
animal foods and fresh antiscorbutic vege-
tables, such as potatoes, water-cress, raw
cabbage, onions, carrots, turnips, tomatoes
and sauer kraut should be used freely.
Orange peel has been found to be anti-
scorbutic. According to A. F. Hess, boiled
orange juice, given intravenously, acts like
a cliarm in scurvy.
Ulcerations in the mouth may be healed
by using a mouth-wash of boric acid solu-
tion. To relieve the swollen, spongy gums
a 2 per cent, solution of tannic acid, or a
mouth-wash containing boric acid, tincture
of myrrh, and compound tincture of ben-
zoin may be used.
Twelve cases of scurvy in the Idiot
Cottages at Kew, Victoria, all in crip-
ples confined to bed or chair, of both
sexes. There had been no alteration
in the dietary of the patients for
years. Other patients suffering from
the same crippled conditions and with
the same foods were unafifected. The
scurvy cleared up in t^^e majority of
cases shortly after the patients re-
ceived a special dietary of raw eggs,
lime water, lemon juice and raw milk.
Lind (Med. Jour, of Austral., Aug. 9,
1919). s. and W.
SCORBUTUS, INFANTILE.
See Infantile Scorbutus.
SCROFULA. See various forms
of Tuberculosis.
SCROFULODERMA. See Tu-
berculosis OF Skin.
SEASICKNESS.— D E F I N I -
TION, — Seasickness may be detined
as an indisposition, characterized by
giddiness, nausea, vomiting, and de-
pression, produced by the motion of
a vessel on the waves. Closely allied
and somewhat similar conditions are
elevator- and car- sickness. Regnault
recognizes two forms of seasickness,
the somatic (gastric) and the psy-
chical (nervous), or that which is the
work of the imagination or results
from seeing others affected.
SYNONYMS.— Seasickness is also
known as naupathia ; nausea marina
seu maritima; morbus maritimus
(L.) ; mal de mer, naupathie (F.).
SYMPTOMATOLOGY. — De
Vries recognizes four stages : depres-
sion, exhaustion, reaction, and con-
valescence. In mild cases the patient
is but slightly ill, sufifering from
malaise and giddiness, followed by
tinnitus, headache, yawning, and
drowsiness, with some gastric dis-
tress. In more severe cases, nausea,
vomiting, vertigo, anorexia, moderate
prostration, a greenish or grayish
pallor, and unsteadiness of gait are
present. In the very ill great pros-
tration may supervene. Constipation
or diarrhea may be present. All the
secretions are diininished (including
the menses) except the saliva, the
flow of which may be excessive.
Diplopia, pain in the eyes, scotoma,
staggering gait, muscular relaxation,
backache, neuralgic pains, alternating
warm flashes and chilliness, weak and
rapid pulse, clamni}^ skin, profuse
diaphoresis, insomnia, fear, and a
feeling of general depression are com-
monly noticed. There are more often
mental depression, nervous exhaus-
tion, unpleasant delusions of the
senses of taste and smell, and. more
SEASICKNESS (WITHERSTINE). HI
rarely, deficient intellectual control, center, which, with the nuclei of the
One of the first symptoms in certain- eighth nerve, also lies in the fourth
cases is an abnormal appetite, which ventricle. There follows obstinate
appears as soon as rough water is vomiting, often associated with great
encountered. prostration. The endolymph follows
COMPLICATIONS AND SE- the motion of the head in those
QUEL.ffi. — Cerebral hemorrhage or canals whose plane corresponds most
the rupture of a previously existing nearly to the direction of that mo-
gastric ulcer is not infrequent, tion, and when the motion is sud-
Brewer, U. S. A. Medical Corps, men- denly reversed by the oscillation of
tions a case in which the vomiting the ship, or changed in direction by
was so severe that a vessel in the a new wave striking her on another
stomach was ruptured and consider- point, the endolymph continues in its
able blood lost ; the child was ill for original direction until stopped by
several days after landing. He re- friction. This causes undue pressure
ports another case in which a phy- in one or more of the ampullae, by
sician who, in addition to the usual which wrong impressions are con-
symptoms, sufifered from a severe veyed to the sensorium, and in-
diarrhea whenever the sea was rough, co-ordination and giddiness result.
Among the most frequent sequelae Moreover, the otoliths are washed up
are vertigo, anorexia, constipation, against the nerve filaments at the
nervousness, and invalidism, these front of the semicircular canals and
symptoms persisting after the patient produce an excessive irritation, which
has left the ship. Bushby, of Liver- is expressed in vertigo and vomiting,
pool, reports two cases of severe, James L. Minor, of Memphis, calls
prolonged prostration following sea- attention to the freedom of deaf-
sickness and associated with aceto- mutes from seasickness as a proof of
nuria. Beard mentions the case of a its aural origin, adding that nausea
man, sick an entire year at sea, who and dizziness are results of irritated,
could not enter any place where the but not destroyed (as in deaf-mutes),
air was foul without feeling the semicircular contents,
symptoms of seasickness. . The theory that "anemia of the
ETIOLOGY. — The etiology of sea- brain" causes seasickness was ad-
sickness is far from being absolutely vanced by C. Binz, of Bonn. He
settled. Many theories have been claims that (1) the motion of the ship
advanced, of which the "endolymph causes constriction of the arteries of
theory" is the most generally ac- the brain and consequent anemia of
cepted one. According to William that organ ; (2) this acute, local ane-
Edgar Darnall the motion of the mia gives rise, as at other times, to
waves with the rhythmic intervals be- rapidly recurring nausea and vomit-
comes transmitted to the endolymph ing; (3) the retching and vomiting
of the semicircular canals. This con- then increases the volume of blood in
tinual flowing in a given plane over- the brain and, in that way, relieves
irritates the fine hair-like terminals of the cerebral anemia and removes the
the vestibular nerve in the labyrinth, sense of nausea ; (4) the stomach
and reflexes are sent to the vomiting plays a passive role, being influenced
112 SEASICKNESS (WITHERSTINE).
by the central nervous system to act pressed in nausea and alteration in
whether it is empty or full; (5) every- the respiratory movements,
thing that facilitates the flow of blood Dubois ascribes a causal relation to
to the brain, and increases the same, incomplete ventilation of the lungs,
acts as a prophylactic, mitigates, or with an increase in residual air,
cures the seasickness. and imperfect respiratory changes.
Germane to this is the "theory of The secondary phenomena, headache,
Pflanz," that the constant change in vomiting, and chills are referred,
blood-pressure and in the fullness of etiologically, to the spasmodic and
the blood-vessels produces an irrita- forcible contractions of the diaphragm
tion in the brain which, when it with a consequent displacement of
passes the stage at which it can the viscera.
be borne, evokes the characteristic Kenneth F. Lund, of Dublin, after
symptoms of this condition. reviewing the various theories as to
Metcalf Sharpe suggests that the the causation of seasickness concludes
condition is the result of a reflex ac- that (1) the vomiting is not due to
tion of the stomach due to a central the unusual impression of vision, for
stimulus ; the reflex action is trans- it may occur on land, when the eyes
mitted to the solar plexus by the are closed, and even to the blind ; (2)
vagi ; the stimulus probably originates it is not due to smell, as any unpleas-
in disorders of visual accommodation, ant odor may cause vomiting, and
for by paralyzing the accommoda- may occur on land, and to any, in-
tion of one eye, by means of a myd- eluding deaf-mutes, who have sensi-
riatic, he found that the symptoms tive nasal organs ; (3) it is not due to
were greatly lessened. Hewitt, of momentary displacement of viscera,
London, believes that interference for it occurs in swinging or in de-
with the visual center predisposes to scending upon an elevator. The sen-
seasickness, sation is present whether the eyes are
According to W. Janowski seasick- open or closed, but it does not occur
ness is an expression of a mild form in deaf-mutes ; (4) there is some
of oft-repeated cerebral concussion. mechanism in the auditory organ,
The surprise of the mental faculty perhaps the semicircular system,
underlying consciousness, analogous which is directly affected by the oscil-
to strong emotional disturbance, as lations of a vessel at sea, which acts
fright, joy, etc., is given by Losee as as a stimulus to the vomiting center,
the causative agent in this disorder. Finally, the nervous element and
Dastre and Pampoukis believe that power of the imagination, as causa-
there is a combination of etiological tive factors, should not be disre-
factors, of the central nervous sys- garded, especially in those of a highly
tem, the pneumogastric, the splanch- sensitive and nervous temperament,
nic, and the phrenic nerves, and that Age has some etiological impor-
the displacement of the abdominal tance. Children and the very aged
viscera and their slipping motion on rarely suffer from it, although chil-
each other probably cause stimulation dren may, purely out of sympathy,
of the Paccinian bodies of the mes- Females are more frequently affected
entery, the effect of which is ex- than males. Only from Yz to 5 per
SEASICKNESS (WITHERSTINE).
113
cent, of all persons escape. Gihon should occur, raise the head or sit up
estimates that 5 per cent, are immune, awhile. Keep always in the cool air
that 25 per cent, are but little sick, on deck with pleasant companions,
that 60 per cent, are a great deal sick, save for meals and bed, moving about
and that 10 per cent, are distressingly as little as possible, until accustomed
ill. to the ship's motion. Avoid oleagin-
PROGNOSIS. — Seasickness is sel- ous smellsi and the company of those
dom, in itself, a menace to the life of who are seasick, as suggestion is a
a patient. powerful excitant to seasickness.
PROPHYLAXIS.— Choose a fa- Avoid cold food. Vichy and Ap-
vorable season (spring or summer), pollinaris waters may be freely in-
if possible, for the voyage. Avoid
sailing on the long, narrow ocean-
greyhounds which roll with each
dulged in throughout the voyage.
Small and frequent (at least seven)
meals are best. M. Charteris. of
swell and pound the ship into con- Glasgow, insists that the diet for the
stant motion with their powerful first two days should be dry and
engines, but select, rather, one of spare, no full meals being taken, and
the broad-beamed, slow-going boats soups and pastries always avoided,
which are now so well fitted for the If there is any tendency to nausea,
comfort of the passengers, as well as exertion should be avoided, as much
carrying freight. Select stateroom as possible ; the sufiferer should be on
and deck quarters in the middle of his back, with a small pillow under
the ship, near its transverse axis, the the head, or none.
point where the rolling of the vessel As to drugs suggestions are numer-
is least felt. A thorough hepatic ous. No drug or combination of
purge should be taken the night be- drugs is infallible. A. D. Rockwell,
fore embarking, and a saline on the of New York, strongly advises bro-
following morning. Go on board the mization — 100 grains (6,6 Gm.) in
vessel rested in body and with a tran- divided doses daily for three days
quil mind, after a light meal on shore, before sailing, and for three or four
with which a little wine was taken, days after sailing. Veronal (sodium),
but scarcely any other fluids. a favorite with many, is best given
The clothing should be of light, in a suppository cont'aining 7^ grains
pure, woolen material; easy, warm, (0.5 Gm.), although 5-grain (0.3 Gm.)
comfortable, broad-soled shoes should doses may be given in tablet form, by
be worn. A good flannel roller band- mouth. Chloretone, another favorite
age, 12 feet long and 6 inches wide, remedy, may be given in 5-grain
enveloping firmly the whole abdomen (0.3 Gm.) capsules, tablets, or pow-
will frequently afford great comfort ders, every 3 hours for 3 doses, so
and prevent undue movement of the arranged that the last shall be taken
viscera. on embarking. For short voyages
A steamer-chair and rug should be this is usually effective ; for longer
provided. Recline on deck in a shel- ones the drug should be continued
tered place, amidship, on the leeward longer. Validol, higlily recommended
side, comfortably covered and with by many, is best given in liquid form
eyes closed. If cerebral congestion on a lump of sugar, the first dose be-
8—8
114
SEASICKNESS (WITIIERSTINE).
\n^ 30 drops, the second 25 drops, and
tlic third 15 drops, taken an hour
apart, the first dose two or three
lujurs before sailinj^. It may also be
lakeii in doses of 10 to 15 minims
(0.6 to 1 (ini.), repeated half-hourly,
if rc(|uircd, plain (neat), in a weak,
alrolioHc solution, or in li(|uid form.
A j)rophylactir injection of '/,„) ,i;rain
(0.0006 dm.) of atropine sulphate,
combined with Hi, ^rain (0.(X)12 Gm.)
of strychnine sulphate, as sut^^ested
by (lirard and olliers, will d(j much
to inhibit the onset. Avoid the use
of morphine, cocaine, and parej^'oric,
which at times are tlionL,ditlessly
recommended.
TREATMENT.— Whenever the
slis^lUest sensation of illness is felt He
down at once and close the eyes.
Usually one pillow suffices, and if
very ill, none should be used. Two
teaspoon fuls of peptone in sherry
wine, poured over cracked ice, may
be ,i;iven every half-hour, as su£^-
.q'ested by Sinclair Tousey. If the
patient is very ill and cannot eat or
retain food, 11. I'artsch recommends
an egg-nog, prei)ared by mixing the
yolks of two raw eggs with an equal
bulk of good brandy or sherry well-
beaten together, and given in tea-
si)oonful doses at ten-minute inter-
vals. Patients with severe retching
will be made comfortable by lying
down, without a ])illow, the eyes
closed; a pint of beer, ale, or porter
(brown stout) is then taken in six or
eight portions at fivc-minute inter-
vals. Champagne frappe or ginger
ale with 20 per cent, of brandy or
whisky is highly praised by many.
When champagne is used it is advis-
able to allow it to stand until effer-
vescence ceases, that eructations be
avoided. Beef-tea or meat broths, in
tablespoonful doses, may be retained.
Food should always be taken at
least ten minutes before arising in the
morning, and when the patient is ill
all food slunild be taken without rais-
ing the head. The best time to take
any beverage or fo(jd is just after a
l)aroxysm of retching. Should it be
taken before and vomited, then take
another dose immediately afterward,
and that will stay down (11. I'artsch).
The sicker the patient, the oftener he
must eat, and the less at a time. The
bowels should be kept open by laxa-
tives or warm-water enemas.
The drugs most in favor in this
condition aie veronal, chloretone, vali-
dol (the administrati(jn of which has
been already described under ])rophy-
laxis), atropine, atropine and strych-
nine ccjinbined, nitroglycerin (s])iritus
gly eery lis nitratisj, and amyl nitrite.
The bromides have largely fallen into
disuse, except ior rclieviiig the head-
ache, because they tend to disorder
the digestion.
Atro])ine is given, to increase the
cerebral blood-su[)ply and to relieve
atony of the vagus, hypodermically,
in doses of /■'j^o to %(» grain (0.0005
to 0.001 Gm.), to be repeated in three
or fom- hours, if necessary. Atropine
sulphate, ^^o grain (0.0005 Gm.)
may be advantageously combined
with i/;„ grain (0.001 Gm.) of
strychnine sulphate.
Nitroglycerin and amyl nitrite have
been used in full doses.
Rosenthal has shown that every
reflex action can be i)revented by
•apnea. This principle is applied for
the suppression of the vomiting
(which is due to a reflex stimulatitm
of the center in the fourth ventricle)
by directing the patient to take a
series of deep inspirations. The sue-
SENEGA.
115
cessful experiments of Rosenthal have
been repeated by R. Heinz and M.
Kaufmann.
Bier's method of hyperemia has
been successfully used by Rosen and
by Schlag"er to reheve the nausea of
seasickness. The hyperemia was in-
duced by fixing an elastic band
around the neck. This had no influ-
ence on the tendency to vomit when
the stomach was full, but when the
stomach was empty the tendency to
vomit ceased. The band was always
removed at night.
Based on his theory (see Etiology)
M. Dubois advised inhalations of
oxygen under pressure, through the
mouth. These were followed by
rapid improvement. The number of
inhalations was not very large, the
amount of gas inhaled being usually
from 30 to 40 liters. Dutremblay and
Perdriolot attest the efficiency of this
treatment.
Wolf applies hot-water compresses
to the forehead, as hot as can be
borne, and rapidly alternated. They
are at first badly tolerated, but after
a little time they produce a thorough
sense of relief. Adrenalin given in-
ternally has also been praised.
Ahhough the number of cases in
which the writer used benzyl benzoate
in seasickness is small, about 20 in
all, the results in every case were so
satisfactory that he feels justified in
recommending it. In his cases 10
drops were used. As the sea voyage
was short in all cases, he was not
able to determine how long the effect
of the drug would last. Glenn (Calif.
State Jour, of Med., Nov., 1920).
C'. Sumner Withekstine,
Philadelphia.
SENEGA. — Senega (senega, snake-
root) is the dried root of Polygala senega
(fam., Polygalacere), a perennial herb of
eastern and central North America, as far
south as North Carolina. The constitu-
ents of senega are a saponin-like mixture
made up of polygallic acid (about three-
fourths of the whole) and senegin, a
jmall amount of methyl salicylate, resin,
fat, sugar, etc. It contains neither tannin
nor starch.
PREPARATIONS AND DOSES.—
Senega, U. S. P. (the dried root). Dose,
10 to 20 grains (0.60 to 1.20 Gm.).
Fluidcxtractiiin scnegice, U. S. P. (fluid-
extract of senega). Dose, 10 to 20 min-
ims (0.60 to 1.20 c.c).
Syrupns senega;, U. S. P. (syrup of sen-
ega— 20 per cent, of the fluidextract).
Dose, 1 to 2 drams (4 to 8 c.c).
Syrupus scillce compositiis, U. S. P. (com-
pound syrup of squill, hive syrup, croup
syrup, an ofificial substitute for Coxe's
hive syrup, containing 8 per cent, fluid-
extracts senega and squill, and 0.2 per
cent, tartar emetic). Dose, 10 to 30
minims (0.60 to 2.0 Gm.).
Alistura pcctoralis, Stokes, N. F. (Stokes's
expectorant). Dose, 1 dram (4 c.c), con-
taining 2 grains (0.12 Gm.) each of sen-
ega and squill, 1 grain (0.06 Gm.) of am-
monium carbonate, and 10 minims (0.6
c.c. of paregoric in syrup of Tolu. This
is a favorite mixture, though not official.
PHYSIOLOGICAL ACTION.— Senega
is an expectorant, alterative, diaphoretic,
and diuretic The powdered root is irri-
tating to the air-passages and its inhala-
tion causes sneezing. When the root is
chewed a burning sensation follows.
When swallowed in large doses it causes
salivation and gastrointestinal and renal
irritation. It is an irritant to the skin.
Used as an expectorant, it does not
liquefy the secretions, but merely facili-
tates their expulsion; senega, therefore, is
of little use when the expectoration is
tough and scanty. It is usually combined
with other expectorants and diuretics.
Senega is excreted by the bronchial mu-
cous membrane, the skin, and the kidneys,
exerting a stimulating action upon these
organs.
THERAPEUTIC USES. — Senega is
cliicfly used in subacute and chronic
bronchitis, in the chronic bronchitis of
the aged, ijften associated with emphy-
sema, and by some in croup. In bronchial
asthma with emphysema, the drug is
116
SENNA.
SERPENTARIA.
beneficial. Whooping-cough is sometimes
relieved by senega. On account of its
diuretic action senega has given relief in
the dropsy of renal disease and in palpi-
tation unasMiciated with cardiac disease.
In amenorrhea it has given good results.
The use of senega in heart disease is not
advised on account of the depressing ac-
tion of its active principle. In doses of 2
grains (0.13 Gm.) senega has been given
to check uterine hemorrhage. Senega has
been given in chronic rheumatism for its
diaphoretic and diuretic effects.
SENNA.— Senna is the leaflets of
Cassia acutifolia (Alexandria senna) and
Cassia angustifolia (India senna), family
Leguminoseae, freed from stalks, discol-
olored leaves and other admixtures.
The principal constituents, according to
Tschirch, are one or more glucosides,
yielding emodin, an extractive substance
(cathartic acid) and a large amount of
gum resin, the non-fermentable sugar
cathartomannite, a bitter (sennapicrin),
oxalic, malic and tartaric acids combined
with calcium, and a trace of volatile oil.
Senna has a faint, disagreeable odor and a
bitter, nauseous taste.
PREPARATIONS AND DOSES.—
Senna, U. S. P. (senna leaves). Dose, 1
to 2^ drams (4 to 10 Gm.).
Fhiidextractum senivcB, U. S. P. (fluidex-
tract of senna). Dose, J^ to 1 dram (2 to
4 c.c).
Infusum sennce compositum, U. S. P.
(black draught, containing 6 per cent,
senna, 12 per cent, manna and magnesium
sulphate, and 2 per cent, bruised fennel
seeds). Dose, 2 to 4 ounces (60 to
120 c.c).
Syrupus senmu, U. S. P. (syrup of senna,
containing 25 per cent, of fluidextract).
Dose, 1 to 2 drams (4 to 8 c.c).
Piilvis glycyrrhiscE compositus, U. S. P.
(compound licorice pow^der, containing 18
per cent, senna, combined with washed
sulphur, licorice powder, fennel oil, and
sugar). Dose, ^^ to 2 drams (2 to 8 Gm.).
Efficient but unofficial preparations are:
Confectio sennse, N. F. (confection of
senna, containing the pulps of cassia
fistula, prune, tamarind, and fig, with 10
per cent, senna flavored with coriander
oil). Dose, 1 dram (4 Gm.).
Syrupus sennrc aromaticus, N. F, Dose,
2 drams (8 c.c), representing IS grains
(1 Gm.) deodorized senna, 6 grains (0.4
Gm.) jalap, and 2 grains (0.13 Gm.) rhu-
barb, with aromatics.
Syrupus sennie compositus, N. F. Dose,
2 drams (8 c.c), representing 16 grains
(1.04 Gm.) senna and 4 grains (0.26 Gm.)
each of rhubarb and frangula.
PHYSIOLOGICAL ACTION.— Senna
is an active, but not acrid, cathartic, act-
ing in about four hours and producing
copious, yellow stools, with some griping
which may be avoided by combining it
with aromatics. It is a feeble hepatic
stimulant, rendering the bile more watery.
The menstrual flow may be excited by it,
and if given to a nursing woman her milk
thereby becomes a purgative. Injected
into the veins it causes vomiting and
purging, and in overdose a drastic cathar-
tic, but it never produces poisonous ef-
fects. The urine acquires a red color
from senna medication, if it is acid, but
in an alkaline urine the normal yellow
color is more pronounced.
THERAPEUTIC USES.— This drug is
a safe, efficient, and, when combined with
other drugs, a pleasant cathartic for con-
stipation. For children and pregnant
women the confection and the compound
licorice powder are advised. It is contra-
indicated in threatened abortion, hemor-
rhoids, and where the intestines are
inflamed.
SEPSIS, SEPTIC FEVER, SEP-
TIC INFECTION, SEPTIC POI-
SONING, SEPTICEMIA. See
Wounds, Septic.
SEPTUM, DISEASES OF. See
Nose and Nasopharynx, Diseases of.
SERA. See Diseases in whicli
these are used ; also Hematology.
SERPENTARIA. - Serpentaria is
the dried rhizome and roots of Aristolochia
serpentaria, Virginia; or of Aristolochia
reticulata, Texas (fam., Aristolochiaceae).
The Virginian species may be found
throughout the eastern United States,
and is chiefly collected in the mountain-
ous districts south of Pennsylvania and
SHOCK.
117
the Ohio River. Serpentaria, an aromatic
bitter, contains a volatile oil (0.5 to 1 per
cent.), a bitter principle, tannin, starch,
sugar, gum, and resin. It has a warm,
pleasant taste.
PREPARATIONS AND DOSES.—
Serpentaria, U. S. P. (the crude drug).
Dose, 10 to 30 grains (0.60 to 2 Gm.).
Fluidextractum serpentari?e, N. F. (fluid-
extract of serpentaria). Dose, 10 to 30
minims (0.60 to 2 c.c.)-.
Tinctura serpentarire, N. F. (tincture of
serpentaria, 20 per cent.). Dose, J^ to 2
drams (2 to 8 c.c).
PHYSIOLOGICAL ACTION. — Ser-
pentaria has a stimulating effect upon
gastric secretion and is added to other
drugs to increase their absorption and ac-
tivity. It has a mild diuretic and diapho-
retic action. In larger doses it pro-
duces a sense of fullness in the head,
nausea, vomiting and intestinal griping
with frequent evacuations of semisolid
stools. Hemorrhoids are irritated and
menstruation stimulated. It is also an
expectorant.
THERAPEUTIC USES.— Serpentaria
is a good general tonic. It is seldom used
alone. In atonic dyspepsia it is useful,
combined with the compound tincture of
cinchona. In combination with the aro-
matic spirit of ammonia it is beneficial
in pneumonia of a low type, in bronchial
catarrh, and in capillary bronchitis. It is
valued as a restorative in typhus and ty-
phoid fevers. It has been used with bene-
fit in chronic rheumatism, combined with
other remedies. Serpentaria has given
good results in amenorrhea dependent
upon anemia or chlorosis.
SHINGLES. See Herpes Zoster.
SHOCK. — DEFINITION. — A gen-
eral depression of the vital functions due
to traumatism, a profound emotion, fear,
etc., characterized by chemicophysical dis-
turbances in the nervous system, in which
deficient adrenal activity and vasomotor
paresis are prominent features.
SYMPTOMS.— Shock may present it-
self in forms varying in intensity froin
slight depression to profound collapse ap-
proximating death. In severe shock the
temperature is subnormal, the surface is
pale or livid and cool or cold, the skin
being clammy and perspiring freely; the
eyes are staring or half-closed; the res-
piration is shallow and irregular, and
often gasping; the pulse weak, rapid and
compressible or imperceptible. A notable
fall of the ])lood-pressure is usual. These
symptoms in severe cases are accom-
panied by loss of consciousness; in the
less severe cases, consciousness is main-
tained as a rule, but psychic activity ap-
pears to be inhibited, the answers to
questions being monosyllabic and often
unreliable; even in mild shock mentality
may l)e temporarily dull and apathetic.
Weakness of the muscles is a striking
feature, those of the surface being flabby
and impotent; the sphincters also fail to
functionate from this cause, and involun-
tary evacuations may result. The pupils
are dilated, as a rule, and react but slowly
to light. Nausea and vomiting may oc-
cur, but this is rather a favorable sign,
since it is often the precursor of a reac-
tion. Conversely, hiccough and gastric
regurgitation are unfavorable signs. Anu-
ria is frequently noted.
In lethal cases, the mental torpor grad-
ually deepens, syncope comes on, and
death follows. This course depicts that
observed in great injury involving con-
siderable loss of blood, complicated prob-
ably with abdominal or cerebral lesions.
Neurotic individuals and drunkards are
also exposed to this rapidly fatal form.
In some cases the picture is quite dif-
ferent. Maniacal furor seems suddenly to
develop, and the patient throws himself
or his liml)s in every direction, rolls his
eyes, strikes right and left, and cries
out at the top of his voice. Usually ex-
haustion soon comes on through recur-
rence, probalily, of hemorrhage on ac-
count of the violent exertion.
In cases that proceed favorably, the
change for the better is termed the "re-
action." All the abnormal symptoms dis-
appear gradually, the return of the mus-
cular tone being manifested by turning,
shifting position, etc., while the cardiac
symptoms lessen in intensity as the facial
color returns. Some cases at this stage
go through the maniacal type of shock
through unduly rapid resumption of cere-
bral blood-pressure. In some cases it is
a sign of septic infection. The tempera-
118
SHOCK.
ture in a favorable case remains near the
normal, though it may exceed this to a
marked degree in children without indi-
cating that a complication has occurred.
This reaction fever sometimes lasts a
couple of days, then gradually disappears.
As regards the differential diagnosis of
shock, internal Jiciiiorrhage is the main
source of confusion, since a serious trau-
matism capable of causing deep shock is
capable of causing also some organic in-
jury in some part, local or remote, of the
vascular system. This question assumes
especial import after an operation owing
to the possibility of concealed hemorrhage.
In the latter case, however, restlessness,
tossing, frequently repeated yawning, in-
tense thirst, nausea, impairment of vision
due to retinal ischemia, and repeated at-
tacks of syncope are apt to occur. Re-
peated examinations of the blood will
serve to place the differential diagnosis
on a surer footing, since hemorrhage pro-
duces a gradual diminution of the hemo-
globin percentage, while uncomplicated
shock does not cause such a change. The
cell count, both as to erythrocytes and
leucocytes, may, however, indicate a
marked decrease, but this is probably due
to recession of the blood-mass into the
splanchnic area, with resulting ischemia
of the superficial vessels. It is, therefore,
an unreliable sign. An abdominal hemor-
rhage may give the physical signs of an
increasing accumulation of fluid. While
the onset of uncomplicated shock is as
a rule sudden, the exhaustion due to hem-
orrhage is gradual, and finally attended
with severe asphyxic phenomena, which
are relatively slight in shock.
Delayed shock may come on some
hours after an injury or a violent com-
motion or emotion, such as is witnessed
in street-car or railroad accidents. Anes-
thetics, especially chloroform and ether,
inay also be followed by shock, not only
in the course of buti after their use.
Shell Shock. — The European war has
shown that shells, mines, and other
agents of destruction in which high ex-
plosives are employed may, irrespective
of or without direct physical injury, give
rise to nervous and psychic phenomena
which have been variously attributed to
"shock," "physical trauma," "concussion
cerebri," etc. In the milder cases, con-
sciousness is not lost, but there may be,
for a time, severe pain in the head and
spine, incoherent speech, trembling, heavi-
ness of the extremities and temporary
anuria. When micturition is re-estab-
lished, the urine may be found to contain
albumin. Uneventful recovery is usual.
In the more severe cases, unconscious-
ness, lasting an hour or more, is fol-
lowed by a severe "bursting" headache
with some deafness, tinnitus and vertigo,
sweating, and tremor, or rhythmic spas-
modic movements. Incoherence of speech,
mutism, amnesia and various disorders
may appear. Catalepsy, followed by con-
vulsions, has also been witnessed. The
reflexes are increasingly active, and se-
vere pain with hyperalgesia in various
parts of the body, including the appen-
dical region, may be complained of. The
cases usually recover in from one to three
weeks. Epilepsy has also appeared in in-
dividuals in whom a history of this dis-
ease did not exist.
Case of a young man buried in a
trench by the explosion of a shell,
who was unconscious when rescued.
Consciousness was regained in a few
hours, but he was totally amnesic
so far as his whole life was con-
cerned prior to and including the
time of the accident. No efforts to
recall his past life were successful,
but the practice of hypnotism brought
out a startling result. While under
hypnotic influence he lost his new
personality completely and returned
to his original one with equal com-
pleteness. During this state he was
able to recognize his father, remem-
bered all of his past life to the mi-
nutest detail, and could even give an
accurate account of the accident
which caused his mental disturbance.
Upon recovery from hypnosis each
time he would relapse into his new
personality and have no memory of
his former one. During the studies
made of him in each of his two per-
sonalities, it was observed that his
voice and his handwriting were dif-
ferent in the two states. In one re-
spect his original personality was
retained to a certain extent, namely,
SHOCK.
119
his ability to play a certain musical
instrument. Anthony Feiling (Lan-
cet, July 10, 1915).
Serious disturbances are produced
by wounds of remote localities, and
are not necessarily psychogenic. The
shock of the wound may cause pro-
longed unconsciousness froin which
patient emerges speechless or voice-
less. Physical shock must be in-
voked to explain such cases. A re-
flex cause could be excluded. The
disturbances in question comprised
aphasia, phonasthenia, dysarthria in-
cluding the spastic form, and kine-
toses of all kinds, very often ac-
companied with exhaustive states.
Treatment was, for the most part,
imperfectly successful with occa-
sional good results. One soldier
upon recovering from shock after
protracted unconsciousness showed
total aphasia. As this passed off
dysarthria and dysphasia were left
and persisted for eight months. After
this bradylalia was the only symp-
tom in evidence. Thirteen months
expired before he could resume his
duties as officer. Gutzmann (Berl.
klin. Woch., Feb. 14, 1916).
This fortunate issue is not, however,
the invariable one. In some individuals,
after weeks or months, the patients,
though apparently recovered, show signs
of a changed disposition, manifested espe-
cially in abnormal irrital)ility, anxiety,
apprehensiveness, or a condition of high
emotional state. These may be attended
with hallucinations, horrifying dreams, de-
lusions, etc. They lose interest in them-
selves and in others, become unsocial and
morose. The repeated revival of memo-
ries of horrible events in the trenches, the
death of comrades, shell bursts, blowing
up of their trench, etc., serve to sustain
the psychic disturbance. The majority of
these cases recover, however, but only
under well-directed psychotherapy, in
which sympathy is freely dispensed.
Wounds tend to aggravate the trouble,
and even to produce it.
The direct effects of the contusion
from the air are of extreme variety,
as also the various conditions that
may be observed afterward. Sudden
death from the shock alone is not
rare; immediate unconsciousness is
common. It may last for hours or
weeks and be followed by total loss
of memory for the period since the
explosion. The effects of the injury
are, in reality, nothing but traumatic
hysteria. When the shell explodes
near a sleeping person, it does not
induce the nervous and mental dis-
turbances otherwise observed. This
throws light on the importance of
the fright as a factor in the shock.
The emotional-neurotic factors are
supplemented by the traits for which
physical exhaustion is responsible.
An exhausted nervous system feels
the effect of the explosion more than
when fresh or well rested. R. Gaupp
(Beitrage z. klin. Chir., Apr., 1915).
From the 156 cases studied, a large
majority of so-called shell-shock
cases admitted into the hospital with
functional neurosis in some form
occurred in individuals with a nerv-
ous temperament, or with an ac-
quired or inherited neuropathy. In
a certain numl)er of cases the cumu-
lative effect of active service had
produced a neurasthenic or hysteric
condition in a potentially sound in-
dividual. Among the large number
of officers the writer has seen sent
back on account of neurasthenia,
none have exhibited symptoms of
functional paralysis or mutism. Cases
which were supposed to have de-
veloped epilepsy as a result of shell
shock were, usually, individuals who
were either epileptics or potential
epileptics prior to the shock. F. W.
Mott (Lancet, Feb. 26, 1916).
ETIOLOGY AND PATHOLOGY.—
Although the term "shock" is applied to
a definite clinical syndrome as a rule, it
is often made to cover, pathogenetically,
very different conditions: hemorrhage,
asphyxia, reflex inhibition, etc. Each of
these, however, has its own pathology:
cerebral ischemia in hemorrhage; deficient
cellular oxidation in asphyxia; vasomotor
paresis in reflex inhibition, etc. True
shock, however, has a patliology of its
120
SHOCK.
own, changes having been shown to occur
in the nerve-cell in keeping with the older
teachings based on the histological
methods of Golgi, Marchi and Nissl in
"shocked" animals. The alterations found
by the Golgi method consist in a de-
formity of the cell-body advancing to the
grade of actual atrophy, node-like swell-
ings on the dendrites, and fragmentation
of the same. By the Marchi methods
there is noted degeneration of various
spinal tracts and columns. As observed
by the methods of Nissl, the cytological
alterations are various, but pronounced.
Chromatolysis is present in a large number
of cells. Changes in the nucleus, — disloca-
tion or vcsiculation, — are also noticeable.
As a result of the central disorder, the
vasomotor system becomes more or less
incompetent, and reduction of the blood-
pressure follows; the peripheral and cere-
bral vessels are depleted, while the larger
trunks within the abdominal cavity are
engorged. This may explain the greater
danger of a fatal issue when much blood
has been lost, the medullary and spinal
changes being thus accentuated.
That the adrenals become inadequate
from the same morbid action on their
governing center — the sympathetic center
according to Sajous — seems probable, thus
furnishing another causal factor for the
low blood-pressure noted. According to
Crile the adrenal adynamia resulting from
shock is a prominent factor of this con-
dition.
The labors of Elliott and Cannon,
Seeley and Lyon have shown that
marked epinephrin exhaustion occurs.
From the fact that the adrenal ordi-
narily contains enormous loads to
tide the individual through emergen-
cies it would seem that the storage
and discharge factors are paramount
over the secretory roles. Further
than this, the amounts of epinephrin
needed to maintain vasoconstriction
that exists in shock are evidence of
the continued output of that secre-
tion as long as an available supply
exists. The adrenal cortex in shock
seems unaffected. J. F. Corbett (St.
Paul Med. Jour., xvii, 655, 1915).
Increased quantities of epinephrin
are thrown into the blood during con-
ditions of low blood-pressure and
shock. The apparent outpouring of
epinephrin is not merely a hasty dis-
charge and depletion of the supra-
renals; since the quantity of epi-
nephric material in the blood actually
increases with the prolongation of
low blood-pressure and shock, there
must be an active secretion from the
glands. The suprarenals seem to
function as a line of secondary de-
fence against a falling blood-pres-
sure. The presence of epinephrin in
increasing amounts as shock pro-
gresses points to an attempt on the
part of the circulation to redistribute
the blood, bring about peripheral con-
striction of the arteries wherever pos-
sible, and thus maintain normal pres-
sure. Bedford and Jackson (Proc.
Soc. of Exper. Biol, and Med., 13, 85,
1916).
The writer defines shock as a grad-
ual progressive fall of blood-pressure
due to a paresis or paralysis of the
musculature of the arterioles. The
only way in which he has been able
experimentally to produce anything
like shock is removal of the adrenals.
Adrenalin produces a good effect in
shock not only because it raises the
blood-pressure, but because it sup-
plies a something which is essential
and in these cases apparently lacking.
The treatment of surgical shock con-
sists in continued administration of
adrenalin plus efforts to remove the
causative factor. J. E. Sweet (Amer.
Jour. Med. Sci., May, 1918).
Owing to these organic disturbances,
the contractile power of the vessels is lost,
the arteries and capillaries becoming de-
pleted through partial transfer of the blood
into the deeper venous trunks, thos^ of the
splanchnic area in particular. As a re-
sult, various organs, especially those far-
thest from the splanchnic area, the brain,
skin, etc., and those of the thoracic cavity
are rendered ischemic. Hence the low
blood-pressure, the feeble heart action
(due in part to deficient adrenal secretion
and the resulting deficient contractility of
its musculature), the deficient respiratory
activity and the profound adynamia ob-
served in shock.
SHOCK.
121
Henderson (1908) has attributed shock
to a loss of carbon dioxide through the
intermediary of the blood and tissues in
the course of operations or severe solu-
tions of continuity. Seelig, Tierney and
Rodenbaugh (1916) have sustained this
view by using intravenous injections of
sodium bicarbonate in shock, the benefit
obtained being attributed to the power
of this salt to break up in various tissue
fluids and thus liberate carbon dioxide.
More recently fat embolism, acidosis,
and absorption of toxic products of auto-
lysis of injured tissues have l)een empha-
sized as important or essential factors in
the production of shock.
Fat embolism emphasized as a
cause of shock. An undoubted rela-
tion exists between shock and broken
bones, particularly when large, as the
femur. In 8 experiments on cats, in-
jection of fatty substances into the
jugular vein induced a clinical pic-
ture essentially similar to traumatic
shock in human beings. Fat, ofien
in large quantities, is known to enter
the blood vessels in traumatic shock.
The injurious effects are due to fat
embolism. W. T. Porter (Boston
Med. and Surg. Jour., Sept. 6, 1917).
Where there is low blood-pressure
in shock, hemorrhage, or gas bacillus
infection, there occurs a diminution
in the available supply of alkali and
hence an acidosis. Operations in
shock and acidosis cause rapid fall of
blood-pressure and sudden decrease
in alkali reserve. Intravenous injec-
tion of sodium bicarbonate produces
quick relief of acidosis and a rise in
the blood-pressure in shocked men
after operation. Cannon (Jour. Amer.
Med. Assoc, Feb. 23, 1918).
Report of investigations showing
the extreme toxicity of crushed mus-
cle tissue, even when aseptic. Ab-
sorption of this muscle autolysate is
undoubtedly a factor in traumatic
shock. Crushed tissues in wounds
should' be cleared out as an emergency
measure at once, without waiting for
shock to subside. Dclbct (Bull, dc
I'Acad. de med.. July 2, 1918).
Kinetic Theory. — On the basis of some
1200 experiments, Crile, of Cleveland, was
led to conclude that the key to shock is not
in the vasomotor system alone, but in the
whole motor mechanism of the body.
Those parts of the body having the great-
est number of nociceptors — nerve-endings
through which defensive reactions are
provoked — and which defend the most
vitally important structures, are those
most active in producing shock on re-
ceiving trauma. Thus, the brain, pro-
tected as it is by the cranium, is not pro-
vided with such nociceptors, does not to
any marked extent awaken shock under
operation as a rule; the abdominal struc-
tures, on the other hand, which are richly
provided with nociceptors, readily pro-
duce shock when subjected to trauma.
Now, the physical basis of Crile's theory
is that when, as is the case under the
influence of certain anesthetics, ether for
example, the reflex motor activity which
normally occurs by stimulation of the
sensitive nerve-endings fails to occur, and
there is no response, the impulses which
reach the cortical centers from the periph-
eral nerve-endings excite and finally ex-
haust these centers, and produce in them
degenerative lesions similar to those that
histologists long ago identified as the char-
acteristic cellular lesions of the condition
known as shock.
Crile attributes these central morbid
changes to "work," i.e., excessive oxida-
tion or febrile process carried on by
those organs which alone are capable of
transforming latent into kinetic energy,
those constituting his "kinetic system,"
the principal organs of which are the
brain, the thyroid, the adrenals, the liver,
and the muscles. According to Crile, "the
brain is the great central battery which
drives the body; the thyroid governs the
conditions favoring tissue oxidation; the
suprarenals govern immediate oxidation
processes; the liver fabricates and stores
glycogen; and the muscles are the great
converters of latent energy into heat and
motion." Yet it is evident that, as
Sajous first pointed out in 1903 (when he
showed that the adrenal secretion circu-
lated in the brain-cells), it is to the pres-
ence in excess of the adrenal principle
that the lesions in the nerve-cells are due,
for Crile calls attention to the "striking
fact" that "adrenalin alone causes hyper-
122
SHOCK.
chromatism, followed by chromatolysis,
and in overdosage causes the destruction
of some brain-cells."
But it is not only the stress of trau-
matism or operative procedures on the
body which so morbidly affects the nerve-
cells of the cortex among others, but also
fear, anxiety, the anticipation of a surg-
ical operation, emotional excitement, etc.
All these factors added to the surgical
traumatism enhance the morbid influence
of the latter on the nerve-cell.
How prevent or, at least, reduce these
effects, which in the aggregate constitute
the condition we term "shock" and which,
moreover, reduce the chances of operative
recovery? This phase of the question is
considered below in the subsection on
Prophylaxis, under the title of "anoci-
association," a term given by Crile to the
measures through which the pathogenic
stimuli to the brain may be controlled and
at least in a great measure prevented.
PROPHYLAXIS.— The prevention of
shock during operations is receiving
greater attention as time progresses. Be-
fore resorting to any serious surgical pro-
cedure the volume of urine excreted in
the 24 hours should be ascertained, and
an examination of the urine itself made,
to ascertain that the kidneys are normal.
This is important, since diseases of
these organs predispose to shock. The
excretion of urea should be ascertained,
for if it falls below 2 per cent, metabolism
is deficient; such a condition points to
asthenia which in turn predisposes to
neurasthenic shock. Violent purging pre-
disposes to a similar condition; hence,
while freeing the intestinal contents is
advisable before operation, it should be
done only by means of aperients, or rectal
flushing with saline solution. Some sur-
geons advise the use of morphine hypo-
dermically, ^ grain (0.008 Gni.) given 20
minutes before the operation to quiet the
patient, besides the influence of whatever
anesthetic is used in that respect; yet
others are opposed to opiates in any
form. The truth lies between the two
extremes; large doses should be avoided.
The manner in which the anesthetic is
administered has much to do with the
production of shock. To clap a towel
saturated with ether on the face of the
already frightened patient and, as far as
his own experience is concerned, literally
choke him, and have a rough orderly hold
his arms and legs to prevent struggling,
besides advertising the surgeon and his
assistants as tyros, favor the production
of precisely the histological changes in
the central nervous described above under
Pathology as those peculiar to shock.
Everything should be done to divest the
patient of fear by telling him that he
will soon be asleep, perhaps feel a little
"stuffy" and the next instant (as regards
the patient's own experience is concerned)
awake in his own bed. By thus sug-
gesting that he will be subjected to no
suffering either through the anesthetic
or the operation much can be done to
pacify him and otherwise avoid shock. By
using the drop method, Allis's inhaler or
any other device which insures the pa-
tient an ample proportion of air, and
avoiding all rough handling, but little if
any struggling will occur.
Another important feature is to main-
tain the surface temperature to its nor-
mal level as nearly as possible by covering
the parts other than those exposed for
operative purposes, with warm blankets
and hot-water bottles outside of these
(and not in immediate contact with the
skin, which may thus be burnt) to sus-
tain the heat. The loss of surface heat
when the body is allowed to become cold
causes accumulation of the blood in the
splanchnic area, an important pathologi-
cal feature of shock. For the same
reason as little* blood as possible should
be lost and the operation performed as
rapidly as safety and thoroughness will
warrant.
ANOCI-ASSOCIATION.— W e have
seen under the heading Kinetic Theory un-
der Pathology, that Crile means by this
term a physical exhaustion of the cerebral
nerve-cells, brought about by abnormally
active stimuli, trauma, pain, fear, emotion,
etc. His experiments showed, moreover,
that the central lesions produced in the
course of surgical operation could be
prevented by blocking, as it were, the
connection between the traumatized part
and the brain-cells by a technique to
which he gave the name "anoci-associa-
tion." Morphine and scopolamine having
SHOCK.
123
been found to conserve the output of
energy, thus avoiding the transmission of
excessive stimuli to the brain-cells, they
form the foundation, as it were, of his
method. His technique, as exemplified by
its application in abdominal work, is as
follows: —
In patients other than infants, the aged,
and the asthenic, Crile administers, on an
average, % gr. (0.01 Gm.) morphine and
Kno gr. (0.0004 Gm.) scopolamine one hour
before operation. If local anesthesia alone
is employed, novocaine in 1:400 solution
is used by local infiltration. , If inhalation
anesthesia is employed, nitrous oxide is
administered, either alone or with ether
added as required. As soon as the pa-
tient is unconscious, first the skin and
then the subcutaneous tissues are in-
liltrated with 1:400 novocaine. The novo-
caine is spread by immediate local pres-
sure with the hand. Incision through this
anesthetized zone exposes the fascia,
which is novocainized, subjected to pres-
sure, and then divided. In succession also
the remaining muscles or posterior sheath
and the peritoneum are infiltrated with
novocaine, subjected to pressure, and di-
vided within the blocked zone. If the
blocking has been complete, then within
the opened abdomen there will be no
increased intra-abdominal pressure, no
tendency to expulsion of the intestines,
and no inuscular rigidity.
The peritoneum is next everted and in-
filtrated with a Zl-i per cent, solution of
quinine and urea hydrochloride, so that
the line of proposed suture is completely
surrounded. As before, momentary pres-
sure serves to spread the anesthetic. This
infiltration of quinine and urea hydro-
chloride serves as a block which may last
for several days. It prevents or minimizes
postoperative shock. It causes a certain
amount of edema of tissue which lasts
for some time after the wound is healed.
With this technique the relaxed abdom-
inal wall permits the easy and gentle ex-
ploration of the entire abdominal cavity.
If there is no cancer in the field of oper-
ation and if no acute infection is present,
then the following regions may be blocked
as completely and in the same manner as
the abdominal wall — namely, the meso-
appendix, the base of the gall-bladder, the
uterus, the broad and the round ligaments,
the mesentery, and any part of the pari-
etal peritoneum. Since operations on the
stomach and intestines cause no pain if
they are made without pulling on their
attachments, no novocaine block is re-
quired in such operations.
In operations carried out in this manner
the closure of the upper abdomen is as
easy as the closure of the lower; all is
done with ease in perfect relaxation. No
matter how extensive the operation, how
weak the patient, or what part is involved,
if the technique is perfectly carried out,
the pulse rate at the end of the operation
is the same as at the beginning. The
postoperative rise of temperature, the
acceleration of the pulse, the pain, the
nausea, and the distention are minimized
or wholly prevented according to Crile.
The cause of the high mortality of
operations on the gall-bladder is ex-
haustion and shock, the exhaustion
of the vital organs of the body. In
excision of the liver and adrenals
within a few hours the blood be-
comes acid. In every case of ex-
haustion the same changes were
found in the brain, liver, and the
adrenals. Postoperative pain finally
overcomes the margin of safety and
the patient dies. Neutralization of
the acids is one of the most impor-
tant functions of the liver. Every
response to stimuli produces an acid
condition. The margin of safety is
reduced in exhausted patients by
this acidosis. An increased acidity
always accompanies inhalation anes-
thesia. Ether, however, adds an-
other strain. The liver finally be-
comes no longer able to neutralize
the acidity. The only cure for the
acidosis is prevention, which may be
largely accomplished by increasing
the store of energy and preventing
the waste of it. Glucose and bicar-
bonate of soda and sleeping in the
open air will increase the store of
energy. Morphine does not increase
the aciditj^ of the blood, but if the
latter is once produced by emotion,
starvation, or whatever cause, large
doses of morphine will then rob the
body of its power to neutralize the
124
SHOCK.
acidosis. But if given before the
acidosis occurs, the morpliinc will
not have anj' effect. Psychic rest is
obtained by twilight anesthesia. If
the margin of safety is very narrow
the operation should be done in two
stages. Avoidance of injury to the
splanchnic nerves is insisted upon.
Crile (X. Y. Med. Jour., July 4, 1914).
As a preliminary narcotic a com-
bination of omnopon and scopolamine
is recommended. It is also valuable
to give a dose of veronal on the
evening preceding the operation. The
writer's method of producing local
anesthesia for abdominal operations
is essentially the anesthetization of
the several nerve-trunks laterally
upon the abdomen through 5 or 6
punctures. The solution consists of
0.4 Gm. (6^2 grains) of potassium
sulphate and 12 drops of synthetic
adrenalin to each 100 c.c. of ''/^
per cent, solution of novocaine. All
the tissues, from the skin to the
peritoneum, should be infiltrated at
the site of each puncture. In addi-
tion to this the line of incision is
infiltrated in a similar manner, and,
if necessary, additional infiltration of
the mesenteric attachments, etc., may
be made. With his technique the
writer had only 2 cases of post-
operative shock in well over 2000
cases. H. M. W. Gray (Brit. Med.
Jour., Aug. 22, 1914).
To illustrate the value of anoci-
association, the writer offers a table
of all hysterectomies operated on
since the adoption of the necessary
technique. Excluding 2 legitimate
exceptions, the average pulse rate
for 17 hysterectomies the evening be-
fore operation was 89; the average
pulse rate the evening after was 80.
Some of these patients were very
much exsanguinated by prolonged
hemorrhages and some had large
tumors. The value of the method
seems incontestable. J. M. Wain-
wright (Penn. Med. Jour., Dec, 1914).
The writer advises that glucose
solution be given as a routine after
every operation in which one has
reason to fear more than the ordi-
nary amount of postanesthetic shock;
it should be given as a routine in
every case in which postoperative
oral feeding may be difficult or in-
sufficient for a considerable period
after operation; it should be given
as an emergency measure either be-
fore or after operation for the relief
of an existing or threatened acidosis.
Burnham (Amer. Jour. Med. Sci.,
Sept., 1915).
TREATMENT.— Raising the limbs and
body in such a way as to cause the blood
to gravitate .toward the head, followed
by absolute rest and quiet in the recum-
bent position, and the external application
of heat (taking care that the skin be pro-
tected by the blanket or that the water-
bottles or bags used be wrapped in cloths
or flannel, lest they burn the patient)
around the trunk and extremities, are the
first measures to be resorted to.
Having treated 6667 wound cases,
the writer divides shock cases into 3
major groups, viz., nervous, hemor-
rhagic, and toxic. A group apart is
that by exposure or exhaustion. Of
103 cases of hemorrhagic shock oper-
ated upon at once, 96 recovered, tend-
ing to show the advisability of imme-
diate operative hemostasis in hemor-
rhage cases, whether shock is or is
not present at the same time. Under
nervous shock are placed concussion,
multiple wounds, or extensive con-
tusions. In these, the system has
reached the extreme limit of its re-
sisting powers and treatment is often
disappointing. In 4 cases of grave
nervous shock, however, expectant
treatment and postponement of oper-
ation were followed by recovery. In
toxic shock from absorption, an op-
portunity for recovery is afforded
only by prompt removal of the toxic
tissues. Of 13 cases thus treated, all
recovered. Gatellier (Presse med.,
Jan. 17, 1918).
Adrenalin has to a considerable extent
replaced all other stimulants when in-
jected in conjunction with saline solution
into the arterial sytem — for rapid action
— or into the veins. Its effect ma3^ how-
e\ er, be evanescent. Two important
measures developed and found serviceable
SHOCK.
125
during the late war v/ere, intravenous in-
jection of 6 per cent, gum acacia solution
to cause a persistent rise in the blood-
pressure, and the removal of lacerated or
crushed tissues to obviate shock from
toxic absorption.
Locke's solution plus 3 per cent, of
gum acacia used with success in the
treatment of low blood-pressure from
hemorrhage and shock. If there has
been great loss of blood, the Locke
must be preceded I:)y an infusion of
normal saline or sugar solution to
give the heart fluid to pump on, the
mucilaginous Locke solution not be-
ing given in amounts exceeding 150
c.c. (5 ounces). Delaunay (Lyon chir.,
Jan.-Feb., 1918).
In shock the catalase of the blood
and probably of the tissues is de-
creased, owing to diminished output
of it from the liver and probably to
dilution of the blood. Alcohol in
shock greatly increases the catalase
of the blood and tissues by stimu-
lating the liver to increased output.
The beneficial effect of alcohol in
shock and general depression is due
to the increase it causes in the cata-
lase of the blood and tissues, with
resulting increase in oxidation and
decrease in acidosis. Burge and Neill
(Amer. Jour, of Physiol., Feb., 1918).
Shocked patients should be placed
in the quietest available quarters,
kept darkened, with comfortable beds.
The bed may be warmed with a
cradle heated by electricity or an
alcohol lamp. The arterial pressure
should be taken every hour. Mor-
phine is given regularly as it seems
efifective in raising the blood-pressure.
Subcutaneous injections of saline
solution with adrenalin complete the
treatment, and the patient sleeps.
When the blood-pressure has im-
proved to 40 and 70 or 80 mm. Hg,
then operation is to be considered.
Necessity for local as well as gen-
eral anesthesia emphasized. Monery
and Loml^ard (Arch, de med. et de
pharni. milit.. Mar., 1918).
Primary shock tends to lessen
hemorrhage, and if the patient is
kept warm and quiet, the Idood-pres-
sure may return to normal. Partial
recovery, however, may be followed
by secondary shock. The best ex-
planation of this is an accumulation
and stasis of blood in the capillaries
— Cannon's cxoiiia. As a result the
tissues sufifer from oxygen starvation
and the vasomotor and respiratory
centers tend to fail. Acidosis is not
a serious factor in shock. It has
not yet been demonstrated that the
symptoms relieved by sodium bicar-
bonate would not be more definitely
cured by raising the blood-pressure.
The main factor in treatment is to
ensure an adequate supply of blood
to vital organs. A solution of gum
arabic (acacia) injected intraven-
ously in most cases is not inferior to
blood. A 6 per cent, solution of the
gum is best, with 0.9 per cent, of com-
mon salt. Tliis maintains the blood-
pressure indefinitely. Its value is
most strikingly demonstrated after
hemorrhage, though after grave
hemorrhage blood transfusion is the
procedure of choice. W. M. Bayliss
(Brit. Med. Jour., May 18, 1918).
Traumatic or wound shock is due
to toxic material from injured tis-
sues. If the blood-pressure falls
below 80 mm. Hg, the tissues begin
to sufifer from lack of oxygen. In the
treatment, arterial pressure should be
raised by blood transfusion if it per-
sists below this critical level. Crushed
tissue should be removed as soon as
possible. If a limb is shattered and
useless, absorption of toxic material
may be prevented by a tourniquet.
Amputation should be done proxi-
mate to the tourniquet and before re-
moving it. Loss of body heat should
be checked and normal temperature
restored by application of heat.
Since ether lowers the blood-pressure
in shock, it should be avoided. Nit-
rous oxide and oxygen should be
used in a ratio not exceeding 3 to 1,
preceded by morphine. Deep anes-
thesia and cyanosis should always be
avoided. W. B. Cannon (Proceedings
Amer. Med. Assoc, N. Y. Med. Jour.,
June 14, 1919).
Crile's technique for the resuscitation
126
SHOCK.
of a patient is as follows: The patient,
in the prone position, is subjected to
rapid rhythmic pressure upon the chest,
with one hand on each side of the ster-
num, to produce artificial respiration and
promote circulatory activity. A cannula
being then inserted into an artery, toward
the heart, normal saline solution (2 tea-
spoonfuls of sodium chloride — being care-
ful not to use the non-deliquescent table
salt now commonly employed — to the
quart of warm water) is infused through
a funnel connected with the ruliber tub-
ing connected with the cannula. As
soon as the flow has begun, 15 to 30
minims (0.9 to 1.8 c.c.) of adrenalin
chloride (1:1000) are injected at once
with a hypodermic syringe plunged into
the rubber tubing, i.e., into the saline
solution, repeating the dose in a minute
if needed. The rhythmic pressure on the
thorax being exerted with maximum ac-
tivity, plus the powerful contraction of
the arteries, including the coronaries,
caused by the infusion, promptly provokes
a powerful rise of blood-pressure. When
this attains about 40 mm. the heart re-
sumes its action, its contractions steadily
increasing in vigor. As soon as the
cardiac beats are fairly resumed, the
cannula should be withdrawn; otherwise
the marked increase of vascular tension
will drive a torrent of blood into the
tube. Pituitary extract in 1:10,000 solu-
tion seems to sustain the effect on heart
and circulation longer than adrenalin.
An important feature of arterial or
venous infusion is that it should not be
given rapidly; otherwise an excessive
amount of fluid will suddenly accumulate
in the right ventricle, and the heart, al-
ready feeble, will cease altogether to
pulsate.
In prolonged shock, high enteroclysis
or hypodermoclysis of saline solution is
indicated. Dawbarn urged that, whenever
possible, the solution should be intro-
duced into the median basilic vein, but
occasionally a vein in the operating wound
will answer the purpose, or, if necessary,
the solution may be introduced into the
common femoral artery with the aid of
an hypodermic needle attached to a foun-
tain syringe. Next in order of efficiency
to intravenous saline infusions are those
introduced into the rectum. Hypodermoc-
lysis is the slowest of all the methods.
The proper temperature for the solution
according to Dawbarn is about 150° F.,
but this seems high. At least 1 quart,
and sometimes even 2 or 3 quarts, may
be injected, providing the precaution is
taken to introduce the solution slowly.
The time occupied in introducing the fluid
should never be less than ten minutes per
quart. The employment of intravenous
injections before or at the beginning of
the operation is not good practice, since,
by increasing the blood-pressure, it en-
courages free hemorrhage.
Valuable for intravenous infusions in
shock is Ringer's solution, prepared as
follows: —
IJ Calcium chloride.. V/> gr. (0.1 Gm.).
Potassium chloride. 1 gr. (0.06 Gm.).
Sodium chloride... 90 gr. (6.0 Gm.).
Heater 1 qt. (1000 c.c).
M.
Careful asepsis of the arm, apparatus,
and solution is important; also the exclu-
sion of all air from the tube before intro-
ducing the cannula. The solution should
be free from solid particles. A probe-
pointed cannula should always be used.
The temperature of the solution should
be about 100° F.; hotter solutions are of
greater value as a stimulant; an initial
temperature of 108° to 110° F. is well
borne. The fluid is cooled from one to
two degrees by entering the cannula. The
amount of the solution to be injected at
one time varies with the rapidity of the
injection and with the quality and ten-
sion of the pulse; 1 quart, repeated when
necessary, is generally better than a large
amount given at one time. It is of great-
est value in shock accompanied by hem-
orrhage. In threatening cases of this
class direct blood-transfusion should be
resorted to.
As regards medical treatment, Senn
recommended the inhalation of nitrite of
amyl, and the administration of stimu-
lants, such as alcohol, hot coffee, and tea.
Of alcoholic stimulants, hot red wine,
rum, and brandy-punch deserve the prefer-
ence. Alcohol in small doses tends to
raise the blood-pressure by promoting
oxidation and therefore metabolism in
the muscular layer of the arteries.
SHOCK.
127
Opium is contraindicated in the treat-
ment of uncomplicated shock, but atropine
is recommended by J. C. Da Costa, par-
ticularly when the skin is very moist.
Subcutaneous injections of sterilized
camphorated oil is a valuable cardiac
stimulant, 3 or 4 hypodermic syringefuls
being administered every fifteen minutes
until reaction sets in. Digitalis may be
used, but it acts slowly in an emergency.
Strophanthin, using the 1 c.c. (16 minims)
of the 1:1000 solution in sterile ampoules
is far more effective. It should be remem-
bered that in shock the absorption of all
drugs administered by the stomach or
rectum, or even injected into the tissues,
is always slow; hence, care is necessary
to guard against cumulative action during
the recovery of the patient.
Research showing that epinephrin
has no cumulative action. Its action
occurs only on direct contact. The
continual infusion of a weak solution
of epinephrin may prove a useful
measure in therapeutics. It is thus
possible to send the solution continu-
ously into a vein and thus keep up
the blood-pressure permanently while
this is being done — the effect being
dependent on the concentration of
the solution, not on the absolute
amount of epinephrin infused. Straub
(Mimch. med. Woch., June Zl , 1911).
Adjuvant measures, such as the inhala-
tion of oxygen, mustard plasters over the
heart, the spine and shins; an enema of
turpentine, hot coffee, whisky or brandy;
Esmarch bandages around the legs and
arms or a tight abdominal binder to drive
the blood toward the vital organs and
increase the general blood-pressure, are
all helpful. Crile deems an increase of
peripheral vascular resistance advantage-
ous and places his patient in an air-tight
rubber suit which he inflates with an air
pump, thus insuring equable pressure
upon the entire cutaneous surface. Ab-
dominal massage to favor the better dis-
tribution of blood from deeper vessels,
followed by the application of the abdom-
inal binder referred to above, has been
lauded as an efficient measure. Galvanism
of the phrenic has been used to promote
contraction of the diaphragm and there-
fore excite respiratory activity.
ELECTRICAL SHOCK.— The two
main causes of death from shock due to
electrical currents, as stated by Spitzka,
Stanton and Krida and others are cardiac
fibrillation and respiratory paralysis. The
cessation of respiration is a secondary
phenomenon, however, though usually
simultaneous with cardiac arrest. Com-
mercial low-tension currents tend to kill
chiefly by producing cardiac fibrillation.
As the tension is increased the effect upon
the heart becomes less pronounced, but
at the same time the effect upon the
central nervous system becomes more and
more certain as the tension is increased;
so that with high-tension currents death
is more likely to be caused by respiratory
failure, although if the contact is pro-
longed the heart is also stopped. All
evidence points to the central nervous
system as being the chief sufferer from
the effects of currents of more than 4800
volts.
Treatment. — Even in cases of good
contact, as with a high-tension current,
according to Spitzka, there may be no
heart paralysis, but only respiratory fail-
ure, and in such cases respiration may be
re-established spontaneously or artifici-
ally. The prognosis is good only in cases
in which there is some heart action and
respiration, the former, particularly.
The stricken individual must, of course,
be taken out of the circuit, if he be not
already freed from it. Bystanders can
do this with rubber gloves, or with hands
wrapped with thick, dry, woolen material,
by pulling at the victim's clothing, by
sticks of wood, or, if in contact with a
wire, this may be cut with a nipper with
insulated handles. This must be done
with caution, as the momentary arc
formed between the separated ends may
blind the rescuers.
The patient should be laid with the
head a little higher than the body, and
artificial respiration be begun promptly by
compressing the thorax about 18 times
a minute, with the hands applied flat to
the sides and lower part of the chest.
The tongue must be drawn forward, or
the pulmotor may be used if available.
Massage over the heart, faradization, the
electrodes applied to the neck ami heart
region, or adrenalin injection by Crile's
128 SILVER (SAJOUS).
method, may be used to stimulate heart silver nitrate with 2 parts of potas-
action. The epiglottis may be tickled with gj^^^ nitrate, stirring and pouring
the forefinger. Other methods that have .^^^^ ^^^^jj^_ j^ ^^^^^^ ^^ ^ ^^.
been suggested are lumbar puncture, , . , . , ....
venesection, the application of the Leduc '^ard solid, with properties Similar to
current, and, in the last resort, a high- those of the preceding preparation,
tension shock of short duration. S. It is sohible in water, but the con-
tained 66.7 per cent, of potassium
SILVER.— Silver (argentum) in ,^5^,.^^^ jg ^j^jy sparingly soluble in
its pure metallic state has a white alcohol. Used externally,
color and a high degree of luster. It Argcnti o.vidum, U. S. P. (silver
is unafifected by oxygen or moisture, ^^-^^^^ [AgoO], occurring as a heavy,
but is readily attacked by sulphur, brownish-black powder, with a me-
and tarnishes when exposed to air ^^,jj^ ^^^^^ j^ -^ U^l^l^ ^^ reduction
containing hydrogen sulphide. The ^^^ exposure to light. It is very
metal itself is not official, but is used slightly soluble in water, to which it
at times in a colloid state in unofficial ji^^parts an alkaline reaction, and is
preparations. Of its salts, the nitrate ij^goiubig i^ alcohol. Dose, :^ to 2
is most largely used. grains (0.03 to 0.13 Gm.) ; average, 1
PREPARATIONS AND DOSE, grain (0.065 Gm.).
— Argcnti nitras, U. S. P. (silver ni- Argcnti cyanidum, U. S. P. VIII
trate) [AgNOs], occurring in color- (silver cyanide) [AgCN], occurring
less, rhombic plates, with a bitter, as a white, odorless and tasteless pow-
caustic, metallic taste. It is soluble der, gradually turning brown on expos-
in 0.54 part of water, and in 24 parts ure to light, insoluble in water and in
of alcohol. It melts at 200° C. It is alcohol. Formerly used in the prepar-
rapidly reduced by organic matter in ation of diluted hydrocyanic acid,
the presence of light, becoming gray Among the unofficial preparations
or grayish black. Dose, ^ to ^ of silver are the following: —
grain (0.007 to 0.03 Gm.). ^ Silver citrate [AggCoHgOT], oc-
Argcnti nitras ftisus, U. S. P. curring as a white, heavy powder,
(molded silver nitrate, lunar caus- soluble in 3800 parts of water, and
tic), prepared by melting silver ni- sensitive to light. It is considered
trate with ^5 its weight of official non-irritating, and has been applied
hydrochloric acid, stirring, and pour- in substance as antiseptic to wounds
ing into suitable molds. It occurs and ulcers, and injected in solutions
as a white, hard solid, usually in of 1 : 4000 to 1 : 10,000 strength into
cones or pencils, with a caustic taste, the urethra, etc.
and becomes grayish on exposure to Silver lactate [AgC3H503 + H20],
light and organic matter. It is in- occurring in crystalline needles, solu-
completely soluble in water and in ble in 15 parts of water, and turning
alcohol, the contained 5 per cent, of brown on exposure to light. Used
silver chloride remaining undissolved, externally (though irritating) for its
Used externally. powerful antiseptic effect in 1 : 100 to
Argenti nitras mitigattis, U. S. P. 1 : 2000 solutions.
VIII (mitigated silver nitrate; mitigated Albargin (gelatose silver). See
lunar caustic), prepared by melting Albargin in the second volume.
SILVER (SAJOUS).
129
Argentamin (ethylene-diamine sil-
ver nitrate), a solution of 1 part each
of silver nitrate and ethylene-diamine
[CHo(NH2)CH2(NH2)] in parts of
water, A colorless, alkaline fluid,
turning yellow on exposure to light.
Asserted to be non-irritant and more
penetrating than silver nitrate, owing
to the albumin-solvent action of the
containing ethylene-diamine. Used
in the urethra in 0.25 to 4 per cent,
solution, and in ophthalmology in 5
per cent, solution.
Argonin (silver casein), prepared
by precipitating an alkaline solution
of casein with silver nitrate and al-
cohol. A fine, nearly white powder,
containing 4.28 per cent, of silver,
easily soluble in water, forming an
opalescent solution which clears on
addition of sodium chloride. Used as
silver nitrate, generally in 0.5 per
cent, solution.
Argyrol (silver vitellin), said to be
prepared by electrolysis of serum
albumin, addition of moist silver
oxide, heating the mixture under
pressure, and drying in I'acuo. It is
probably a compound of hydrolyzed
protein and silver oxide, and contains
from 20 to 25 per cent, of silver. It
occurs in black, shining, hydroscopic
scales, freely soluble in water and
glycerin, but insoluble in alcohol and
oils. It is not affected by boiling. It
is incompatible with acids, and most
neutral or acid salts in strong solu-
tion. Used as a non-irritant anti-
septic in 5 to 25 per cent, solutions
in urethritis, cystitis, and diseases of
the mucous membranes of the eye,
ear, nose, and throat.
Hegonon (silver nitrate ammonia
albumose), obtained by treating sil-
ver ammonium nitrate with albumose.
A light-brown powder, readily solu-
ble in water, said to contain about 7
per cent, of organically combined sil-
ver. Used as substitute for silver
nitrate for irrigation purposes in
1 : 2000 to 1 : 6000 solutions.
Ichthargan (silver ichthyolate or
ichthyosulphonate), prepared by neu-
tralization of ichthyolsulphonic acid
with silver oxide, and extraction with
water. A brown, stable powder, with
a light chocolate-like odor, asserted
to contam 30 per cent, of metallic
silver and 15 per cent, of sulphur in
organic combination, freely soluble
in water, but incompatible with
soluble chlorides. It is said to com-
bine the bactericidal action of silver
with the penetrating, antiphlogistic
action of ichthyol. Used in 0.04 to
0.2 per cent, solution in gonorrhea ;
3 per cent, solution in posterior ure-
thritis, and in 0.5 to 3 per cent, solu-
tion in trachoma.
Protargol (protein silver salt), pre-
pared by treating proteins with a
silver salt, and rendered soluble by
treatment with a solution of albu-
moses. A light-brown powder, con-
taining 8.3 per cent, of silver in
organic combination, soluble in 2
parts of water. The solution is not
affected by alkalies, chlorides, bro-
mides, or iodides, nor by heat. Its
precipitation by cocaine hydrochlo-
ride is pre-vented by addition of boric
acid. It should not be exposed to
light. Used as substitute for silver
nitrate for irrigation purposes in
1 : 1000 to 1 : 2000 solutions, in 0.25
to 1 per cent, solutions in acute gon-
orrhea, and in 5 to 10 per cent, in-
stillations in chronic gonorrhea, and
in diseases of the mucous membranes
of the eye, ear, nose, and throat.
Colloid silver and its action and
therapeutic uses have been discussed
8—9
130 SILVER (SAJOUS).
under the heading Collargol, in the Where silver nitrate is to be used
third volume, to which the reader is locally at intervals in the form of a
referred. solution, addition of spirit of nitrous
INCOMPATIBILITIES. — Silver ether is considered of value in pre-
nitratc is incompatible with organic venting precipitation. The following
material, becoming transformed into formula is credited to Fox and
the black oxide of silver or black Higginbotham :—
metallic silver. With soluble chlo- ^ Argenti nitratis gr. v (0.3 Gm.).
rides or hydrochloric acid it forms Spiritus athcris nitrosi fSij (8 c.c).
the insoluble silver chloride. It is Aqncc destillatce f3vj (24 c.c).
also incompatible with bromides and
iodides, with alkalies, with acetates, Such a solution may be applied
chromates, cyanides, hypophospites, freely to the conjunctiva, without
phosphates, sulphides, sulphates, and neutralization with salt solution, in
tartrates, with copper salts and fer- all forms of conjunctivitis, from a
rous and manganous salts, with "^i'd "pink eye" to gonococcal con-
antimony salts and arsenites, with junctivitis (Valk).
morphine salts, with alcohol, with Where it is desired to use an oint-
creosote, with oils, and with tan- *"ent of silver nitrate, the following
nic acid and vegetable astringent combination may, with advantage,
preparations. be employed :—
MODES OF ADMINISTRA- ^ Argenti nitratis gr. xv (1 Gm.).
TION.-Silver nitrate, when used Acidi borici pulveris.. '^n.s {li) Gm.),
,, . , ' . . .„ Cerce flava: Sj (30 Gm.).
mternally, is generally given in pills, q^^. ^^-^^ ^^.. ^^^ ^^^
but may also be administered in a yi^
solution of 0.2 per cent, strength, c^., •, . ,, , • •
- , , , , , , Silver oxide is generally adminis-
preterably through a stomach-tube to ^ . . .,, ,
, , ■' . . . , , ., , tered in pill form,
avoid precipitation of the silver be- ^, ,< . ,, .,
, . , , . . ihe organic silver compounds,
tore It reaches the gastric cavity. , , ,
,,,, , . ." , ,, such as protargol and argyrol, are
When thus given, it should soon , . n ,, . , •
r, , , , , r-., used externally, generally in solution,
after be removed by lavage. Silver .^ i_ i i ^-i
. ^ ... , ,, , , . , (bee below, under i herapeutics.)
nitrate pills should be made with ^
kaolin or petrolatum, as glucose, PHYSIOLOGICAL ACTION. -
glycerin, extracts and other materials Locally, silver nitrate is antiseptic
commonly used as excipients render ''^"^ ^'^'y irritating. It is astringent,
the' salt inert. The following form- coagulating proteins, and also caustic,
ula for silver-nitrate pills has been ''^^d^'y destroying soft tissues with
recommended: which it is brought in immediate
■D ^ ,. ., ,. ,o/ /rM ^ A contact in concentrated form. It
tfi Argenti mtratis .... gr. 1% (0.1 Gm.).
c«^;; c.w/,/,^/;,. .^ coats moist tissues with a tough.
iioaii sulpliatis ex- ^
siccati gr. viij (0.5 Gm.). ^^ite film, and has not much
KaoUni •. gr. xv (1 Gm.). penetrating power, though Wildbolz
Aqua destiUata: gtt. x. found 1:1000 to 1:100 solutions to
Fac. in, pilulas no. xx. penetrate to the subepithelial tissue
(Each pill contains V12 grain^^.005 Gm.— in the urethra of the dog. In dilute
of the silver salt). solution it overcomes relaxation of
SILVER (SAJOUS).
131
tissues, and apparently improves
local nutrition. Its local action, if
excessive, can be quickly arrested
with a solution of sodium chloride,
which precipitates it as silver chlo-
ride. Applied to the skin, it produces
a brown and, later, a black stain, on
exposure to light.
The "organic" preparations of sil-
ver, such as argyrol and protargol,
are not precipitated by protein and
sodium chloride, and are not astrin-
gent. Protargol is but slightly irri-
tant, as compared to silver nitrate,
and argyrol hardly irritant at all.
Their efficiency as antiseptics is,
however, far less than that of silver
nitrate, for which, in spite of their
low irritant power, they are not,
therefore, adequate substitutes where
a strong antiseptic action is desired.
Post and Nicoll found the gonococcus
killed in one minute by 1 : 5000 silver
nitrate, but only partially inhibited in
the same period by 10 per cent, pro-
targol, and hardly at all influenced
by 10 per cent, argyrol. Similar re-
sults were obtained in the case of the
pyogenic streptococcus and the pneu-
mococcus, except that a 1 : 1000 silver-
nitrate solution was required to kill
these organisms in one minute. The
typhoid organism, on the other hand,
was killed in one minute only by a
1 per cent, silver-nitrate solution,
though succumbing completely in
the same period to 10 per cent,
argyrol or protargol. The antiseptic
action of silver nitrate is due, not
only to coagulation of the protein of
the bacteria, but also to a specific
action of the metal, silver proteinate
itself being antiseptic.
The bluish-white pellicle which fol-
lows the application of silver nitrate
to the conjunctiva is not coagulated
albumin, but chloride of silver de-
posited in the structure of the mem-
brane. The essential element in
determining the stain is the soluble
chlorides of the tissues. It is chlo-
ride of silver that is decomposed by
light, not albuminous material. The
brown stain is either argentous chlo-
ride or an oxychloride of silver.
Drops of silver-nitrate solution are
more potent in causing a stain than
an application of a stronger solution
by the brush.
The penetration of a 20 per cent,
solution of argyrol as compared with
weak silver nitrate is practically nil.
The amount of silver organic silver
compounds contain is no criterion of
their therapeutic utility. Argyrol may
have a mechanical effect, and its
sedative action is due to the large
amount of silver it contains, metallic
silver being sedative in its action.
Burden - Cooper (Ophthalmoscope,
Jan., 1907).
Silver acetate forms a durable solu-
tion and has the least irritating action
on the tissues of all the silver salts.
It is strongly bactericidal. It is im-
portant to follow its application by
rinsing with water or with a weak
salt solution. Schweitzer (Archiv f.
Gynak., Bd. xcvii, nu. 1, 1912).
Silver nitrate dissolved in water
killed the dysentery bacillus in five
minutes. On the other hand, in
broth, with the addition of a little
organic matter and salts, it failed in
a strength of 1 in 100. The frequent
failure of silver-nitrate injections in
dysentery is thus easily understood.
Albargin gave the best results of any
of the silver compounds in the pres-
ence of broth, as it killed the dysen-
tery bacillus within five minutes in a
dilution of 1 in 500, but it was less
efficient in a second trial. Collargol,
ichthargan, and argyrol had little or
no action in the presence of broth.
Rogers (Indian Jour, of Med. Re-
search, Oct., 1913).
General Effects. — Taken internally
in moderate dosage, silver nitrate has
132
SILVER (SAJOUS).
been held to act as a tonic to the
nervous system, exert a favorable
influence on the blood, and promote
constructive tissue metabolism, but
there exists no delinite pharmaco-
logic evidence supporting these views.
Administered subcutaneously or in-
travenously in poisonous doses in
animals, its characteristic effects ap-
pear to be primary stimulation of the
central nervous system, especially the
medullary centers, followed by de-
pression and paralysis; in slower
poisoning, a marked increase of bron-
chial secretion, ending in edema of
the lungs, has been observed. In
cold-blooded animals,' silver salts are
said to give rise to convulsions in
some ways similar to those of strych-
nine, followed by paralysis. These
effects have no evident therapeutic
bearing. Large amounts of silver
nitrate taken internally produce, by
reason of their caustic action, a vio-
lent gastroenteritis, thrombosis of the
gastric veins, and ulceration of the
gastric mucosa.
Absorption and Elimination. — It is
believed that in man the greater part
of the silver ingested passes through
the alimentary tract unabsorbed. The
remainder is apparently absorbed in
the form of a solution — none of it be-
ing found in the gastric or intestinal
epithelia — and is soon after deposited
in the tissues in minute granules., be-
lieved to consist of an organic com-
pound of silver. That it stays
imbedded thus indefinitely is sug-
gested by the fact that the resulting
pigmentation remains unaltered over
long periods.
Fraschetti and others deny that
any elimination of silver takes place
in man, either through the kidneys or
the intestines.
POISONING.— There are two
forms of poisoning by silver — that
following a large single dose (acute),
and that following the long-continued
use of small doses (chronic).
Acute Poisoning. — The symptoms
of acute poisoning by silver nitrate
are partly gastrointestinal and partly
cerebrospinal. Either series of phe-
nomena may predominate.
Almost immediately after a poison-
ous dose, a burning is felt in the
throat and stomach, and soon aftei'
violent abdominal pain, with vomit-
ing and purging, comes on. The ab-
dominal walls may become hard and
knotted, more rarely scaphoid. The
face becomes flushed or livid, and is
covered with sweat. The expression
is one of anxiety. When vomiting
occurs, the ejecta are often brown or
blackish in color, though sometimes
white and curdy, especially after
sodium chloride has been given. The
lips and mouth are covered with a
grayish-white membrane, which may
later change to brown and then black.
Occasionally, where the poison has
been ingested in solid form, this
membrane is absent.
In some cases the nervous symp-
toms are severe, consisting of inco-
ordination, paralysis, and convulsions
with coma or delirium. The convul-
sions are generally tetanic, persist,
according to Rouget, after complete
abolition of voluntary movements,
and, according to Curci, are due to
excitation of the motor cells of the
cord.
Collapse follows, because of the
gastrointestinal corrosion produced,
and death takes place from asphyxia
due to central respiratory paralysis,
accompanied by a profuse flow of
bronchial secretions.
causmg
pul-
SILVER (SAJOUS;.
133
monary edema. In a case reported
by Ueck coma returned at intervals
during several days before the patient
died.
At post mortem the stomach and
howels are found corroded, often
ecchymosed, and with patches of a
w^hite or grayish color. The lungs
are congested and the bronchial tubes
filled with fluid.
Poisoning by this drug is not com-
mon. The lethal dose is not certain ;
30 grains have killed and recovery
has followed the ingestion of an
ounce.
Treatment of Acute Poisoning. —
The chemical antidote is common
salt (sodium chloride), which should
be administered in large amounts.
Vomiting should then be induced at
once, as the silver chloride formed is
soluble in solutions of sodium chlo-
ride and in the digestive fluids. Lav-
age of the stomach with a very soft
stomach-tube may be carefully tried.
If the stomach cannot be washed out,
one may give large draughts of salt-
water and produce vomiting alter-
nately. Opium and oils may be
given to allay the irritation, and
large draughts of milk administered
to dilute the poison and protect the
mucous membranes. Mucilaginous
fluids and white of egg may also
be used as demulcents. External heat
should be applied if indicated, and in
the event of collapse, the customary
stimulant measures availed of, to-
gether with artificial respiration.
Atropine might prove of value to
counteract the excessive bronchial
secretion.
Chronic Poisoning.- — Prolonged in-
ternal use of any of the soluble salts
of silver gives rise to chronic poison-
ing, or argyria. A local argyria, or
argyrosis, may be caused by the fre-
quent topical application of a soluble
silver salt for a prolonged period.
Discoloration of the eyelids, con-
junctiva, and cornea has been ob-
served from the use of silver nitrate
in the eye, and a similar condition
noted from its local application in the
throat, or a blackening of the hands
from constant working with silver.
A few cases have even been reported
of general argyria resulting from
topical use of silver in the mouth
and throat.
General argyria was formerly more
frequent than now, arising frequently
from the administration of silver ni-
trate in epilepsy. The first sign of it
is the appearance of a slate-colored
line along the gums, associated with
some inflammatory swelling. Later
grayish spots or patches appear on
the skin and mucous membranes, and
spread over the whole body until the
skin has acquired a peculiar bluish-
slate color, which may become very
dark. In decided cases, the conjunc-
tiva and oral mucous membrane are
involved. In some cases discolora-
tion is especially marked in the face.
The silver is found in all the tissues
of the skin below the rete Malpighii,
and is deposited mainly in the con-
nective tissues, the various paren-
chymatous cells, and epithelia of the
body escaping the pigmentation. Al-
though the discoloration is long in
making its appearance, the deposi-
tion in the tissues prol^ably begins
at once, gradual accumulation there-
after taking place. Especially marked
deposition occurs in the renal glo-
meruli, the hepatic and splenic
connective tissue, the mesenteric
glands, the serous membranes, and
the choroid plexus. The connective
134
SILVER (SAJUUS).
tissues throughout the respiratory
passages and alimentary canal like-
wise show silver deposition. The
condition of argyria does not seem
to affect the general health.
Two women were workers in silver
leaf, their task being to cut the leaves
and lay them in books. One, aged
27, had wr rkcd steadily for fourteen
years. The discoloration of the skin
was first noted when she was 18, and
it increased steadily for four years,
then remained the same. It affected
chiefly the exposed parts and visible
mucosae. The other patient, 50 years
old, had begun to follow the occupa-
tion at 14, and had first noticed the
discoloration at 21. Both women
exhibited anemia and disordered di-
gestion several years before the ap-
pearance of the argyrosis. The silver
line on the gums should be watched
for as a danger signal in subjects
similarly occupied. Koelsch (Miinch.
med. Woch., Jan. 30, Feb. 6, 13, 1912).
Argyria has been induced in three
months, and after the use of j/2 to 1
ounce (15 to 30 Gm.) of silver nitrate
(Cushny).
Treatment of Chronic Poisoning. —
Prophylaxis is important. When the
salts of silver are indicated in a pro-
longed course of treatment, occa-
sional discontinuance of the remedy
is imperative. At the end of the
third week, the remedy should be
stopped for one week, and after three
months a long intermission should
follow. In the intermissions of treat-
ment, the patient should receive a
thorough course of purgatives, diu-
retics, and baths. Potassium iodide
may be given with the silver salts to
expedite its elimination.
Greater or less success has been
claimed for various treatments in
argyria, but in general they are futile.
Rogers claims that blistering will
lighten the color, but how it should
do so is not plain, since the silver
deposit lies deep down in the skin.
luchmann recommends the use of
potash baths and of soap baths, each
four times a week. The internal use
of potassium iodide may produce
some change in the color of the skin,
but perfect restoration to the normal
is generally unattainable.
Report of the case of a young
woman, supposedly suffering from
jaundice, which turned out to be
argyrism following a course of col-
largol. A dose of 10 grains (0.65
Gm.) of hexamethylenamine, given
for a coryza, caused marked improve-
ment in the patient's coloration. A.
M. Crispin (Jour. Anier. Med. Assoc,
May 2, 1914).
THERAPEUTICS. — Gastrointes-
tinal Disorders. — Silver nitrate has
been found of some value in the
treatment of gastric ulcer. It is often
given in pill form, sometimes in com-
bination with extract of hyoscyamus
or opium. As hydrochloric acid or
sodium chloride renders it inert by
precipitation of silver chloride, it may
prove useless unless its ingestion is
preceded by lavage of the stomach.
A 1 in 500 solution of it may then be
introduced through the tube to the
amount of Yi fluidounce (15 c.c), and
in a few minutes lavage with plain
water repeated. The dose of silver
nitrate in pill form in these cases is
M to y2 grain (0.015 to 0.03 Gm.).
If it is given in solution, sodium bi-
carbonate may, with advantage, be
added.
Pyrosis is frequently relieved by 1-
grain (0.065 Gm.) doses of silver
oxide, given in pill form, a half-hour
before meals.
In chronic gastritis and gastric
catarrh, when sour eructations or
vomiting occur after meals, the ni-
SILVER (SAJOUS).
135
trate in doses of % to H grain (0.01
to 0.015 Gm.), given an hour before
meals, sometimes yields good results.
Forlanini in these cases, when asso-
ciated with hyperchlorhydria, irri-
gates the stomach with a solution of
silver nitrate, 10 to 30 grains (0.6 to
2 Gm.) to the quart (liter), fol-
lowed immediately by sodium chlo-
ride solution.
Experiments and clinical experi-
ences showed that silver nitrate has
the property of increasing the acidity
of the gastric juice. It is indicated
in hypochlorhydria and in mucous
gastric catarrh. It aids in the diges-
tion of protein. The drug may be
used to advantage in abnormal fer-
mentation. It promotes the empty-
ing of the stomach. These various
effects were observed with small
doses (%2 grain — 0.002 Gm. — three
times a day), as well as with large
amounts (^ grain — 0.03 Gm. — three
times a day). Baibakofif (Archiv f.
Verdauungsk., Bd. xii, nu. 1, 1906).
Catarrhal jaundice has been re-
lieved by i/^o-gi'ain (0.005 Gm.) doses
of silver nitrate. F. Ehrlich has
recommended (1902) the introduction
of a 1 per cent, solution of the salt
into the stomach, after preliminary
lavage with warm w^ater, in angio-
cholitis, cholelithiasis, and chole-
cystitis. The solution is withdrawn
after one-half to two minutes, the
process repeated, and washing with
j)lain water then continued until a
clear fluid returns. The remedy is
asserted to act as a cholagogue and
to relieve the symptoms, sometimes
after preliminary aggravation.
Use of silver nitrate recommended
in all irritative conditions of the
gastric mucosa with increased secre-
tion, hyperacidity, nausea, vomiting,
and pain. In gastric neuroses, how-
ever, the drug exerts no influence
whatever. In the hyperchlorhydria
frequently occurring in chlorosis,
various diseases of the liver, chole-
lithiasis, cholecystitis, the early stages
of nephritis, and reflexly in constipa-
tion, especially of the spastic type,
and in mucous colitis, treatment
should be chiefly directed to the pri-
mary disease, but for the alleviation
of the symptoms silver nitrate is
valuable.
In benign pyloric stenosis with re-
tention of the gastric contents and
decomposition of the retained ingesta,
the most efifective symptomatic treat-
ment is thorough lavage followed by
silver nitrate internally. In fissure at
the pyloric orifice, lavage followed by
silver nitrate, a non-irritating diet,
and olive oil on an empty stomach,
has never failed, in the author's ex-
perience, to effect a cure. For the
pain of gastric ulcer, acute or chronic,
silver nitrate is superior to any other
drug. The heartburn, sour eructa-
tions, headache, and constipation are
also promptly relieved.
Silver nitrate is always well borne
by the stomach. In a case of severe
hemorrhage from gastric ulcer in
which the patient suffered intensely
from sour eructations and laryngeal
spasm, silver nitrate relieved both
these symptoms after the second
dose. In chronic acid gastritis silver
nitrate acts as in other forms of hy-
peracidity. In alcoholic gastritis dur-
ing the hj'peracid stage it should also
be employed. It is important in all
forms of gastritis to wash the stom-
ach thoroughly before the drug is
given.
The writer usually gives the drug
in solution in doses of J4 to ^ grain
(0.016 to 0.03 Gm.) three times a day
on an empty stomach. No food or
drink is followed for half an hour
after its administration. It is rarely
necessary to continue longer than
three weeks, though in rebellious
cases it may he given for a month
without danger of argyria. Where
the intestines react unfavorably it
should be discontinued at once. H.
Weinstein (N. Y. Med. Jour., Dec.
28, 1907).
136
SILVER (SAJOUS).
In ulceration of the cecum or rec-
tum and in acute and chronic dysen-
tery, rectal or colonic injections of
silver nitrate are of value. If the
cecum be invohcd a large bulk must
be used to reach the seat of the
trouble; if the rectum is the part
affected not more than 4 ounces (120
c.c.) should l)e used. In either case
there should be given preliminary
cleansing injections of warm w^ater.
If the condition is cecal, one may use
1 dram (4 Gm.) of silver nitrate to 3
pints (1500 c.c.) of water; if rectal,
5 grains (0.2 Gm.) to 4 ounces (120
c.c).
If the rectal disturbance is chronic
and very obstinate, the strength may
be increased to 5 grains (0.3 Gm.) of
the salt to 4 ounces of water. A
solution of common salt should be at
hand, to be injected if the action of
the silver is too severe, or to stop
the action of the remedy when the
desired effect has been produced.
The antiseptic and astringent prop-
erties of protargol proved effective in
several cases of gastrectasia with py-
loric stenosis, the fermentation, py-
rosis, and vomiting being checked.
Improvement was also noted in
chronic catarrh, gastric ulcer, and
even in carcinoma. Several cases of
dysentery and pseudodysentery were
rapidly cured by intestinal lavage
with a 2.6 per cent, solution of pro-
targol. For the enteritis of children
y2 to % pint (25U to 300 c.c.) uf a 2
per cent, solution were employed.
For gastric lavage a 2 per cent, solu-
tion is used. It is advisable to wash
out first with water, then to intro-
duce 1 quart (liter) of the protargol
solution. After eight or ten minutes,
this is again washed out with water.
For intestinal lavage, a preliminary
washing with water is not necessary.
Cantani (Gaz. degli osped.. No. 138,
1910).
Nervous Disorders. — Silver has
l)cen used in anterior and posterior
spinal sclerosis, and in epilepsy and
chorea, Ijut with little or no favorable
eft'ect, except possibly as a general
tonic.
In tabes dorsalis Curci has claimed
good results from the use of a double
salt, the thiosulphate (hyposulphite)
of sodium and silver. He gives daily
from % to 3 grains (0.048 to 0.2 Gm.)
by mouth or from % to % grain (0.01
to 0.048 Gm.) hypodermically. He
asserts that this treatment does not
cause argyria.
Surgical Disorders. — Fissures of
the lips, tongue, nipples, rectum, and
mucous patches and ulcers of the
mouth yield readily to applications
of a 60-grain (4 Gm.) to the ounce
(30 c.c.) solution of silver nitrate
applied carefully on a pledget of
cotton or by means of a camel's-
hair pencil. In some cases the solid
stick does better. It is also useful in
hemorrhage from leech-bites.
Boils and felons may be aborted
Ly early application of a strong solu-
tion of silver nitrate.
The healing of suppurating ulcers
and wounds, with large flal)by granu-
lations, is hastened by an application,
every day or two, of the solid stick
or strong solution. The surface of
indolent ulcers may be touched
lightly with the solid stick, or a line
may be traced within and parallel to
the margin of the ulcer every day or
two, the ulcer being strapped with
diachylon adhesive plaster during the
intervals and the limb dressed with
a roller bandage. Indolent sinuses
from buboes or from abscesses may
likewise be stimulated to healing
with a strong solution or the solid
stick.
SILVER (SAJOUS).
137
Powdered silver nitrate recom-
mended as a means of exciting the
proliferation of granulations and the
regeneration of epidermis over open
wounds and ulcers. As an excipient
the writer uses fullers' earth (l)olus
alba), sterilized by heating to 100°
or 150° C. The mixture should con-
sist of 1 part of silver nitrate to 99
parts of the earth. It is dusted on
the raw surface (not extending over
the parts already healed over), and
renewed every second or third or
fourth day, according to the amount
of secretion and reaction of the tis-
sues. When the wound is well on
the way to epidermization the treat-
ment should be interrupted from time
to time and simple aseptic dressing
applied. The treatment is recom-
mended especially for burns, and for
the healing of wounds following
furuncles and other infective proc-
esses of the skin. Max. Barnet
(Miinch. med. Woch., Aug. 30, 1910).
Bed-sores can sometimes be aborted
ii, as soon as the surface reddens, it
is brushed over with a 20-grain (1.3
Gm.) to the ounce (30 c.c.) solution
of silver nitrate. This treatment is,
however, frequently of no avail in
paralytics.
Lymphangitis of the forearm re-
sulting from a poisoned wound of
the finger may be cured by applying
the solid stick over the lines of
inflammation.
Rovsing prefers silver nitrate to all
other antiseptics for impregnating
gauze and drainage wicks, and in the
preparation of suture material, and
uses it extensively in his clinic for
these purposes.
Spasmodic esophageal stricture lias
been relieved by the use of a sponge
probang saturated with a very weak
solution of silver nitrate.
Gushing, Halsted, and Lexer highly
recommend the use of silver foil as
a dressing for granulating wounds,
and especially for skin-grafts and the
incisions in plastic operations on the
face. The silver leaf acts as an anti-
Leptic and minimizes scarring.
The marked tolerance of the body
tissues for metallic silver has led to
its use in bone suturing and in the
preparation of supporting filigree or
chain for use in cases of ventral
hernia or other varieties of weakened
abdominal wall.
Miller recommends, as productive
of good scar formation in burns, the
use of an ointment of protargol, 45
grains (3 Gm.), dissolved in cold dis-
tilled water, 75 minims (5 c.c), and
mixed with 3 drams (12 Gm.) of dried
wool-fat and 2^^ drams (10 Gm.) of
petrolatum.
Silver - foil platelets used over
wounds where very inconspicuous
scar is desirable. Wounds thus cov-
ered remain perfectly dry, even if
left alone for a week to ten days,
and epidermization is much acceler-
ated. In osteoplastic flaps the scars
are so faint they are scarcely visible.
Skin grafts may be left untouched for
a week to ten days, though occasion-
ally blood and serum collect beneath
some of the grafts. In granulating
wounds, healthy granulations are
rapidly covered over with epithelium
under the foil, without the formation
of much granulation tissue. They
become flatter. The silver foil ap-
parently has an inhibitory effect upon
the growth of granulation tissue.
The surface, when healed, is even
with the surrounding skin. The sil-
ver foil is also advised in skin
sutures beneath plaster-of-Paris casts.
E. Lexer (Zentralbl. f. Chir., Bd. xlii,
S. 217, 1915).
Disorders of the Respiratory Tract.
— Acute pharyngitis may be aborted
by the early application of a 60-grain
(2 Gm.) to the ounce (30 c.c.) solu-
138
SILVER (SAJOUS).
tion. In laryngitis the parts should
be cleansed with an alkaline solution,
the parts anesthetized with a solution
of cocaine, and by the aid of a brush
and mirror a 10- or 20- grain (0.65
or 1.3 Gm.) to the ounce (30 c.c.)
solution of silver nitrate applied to
the larynx.
In laryngeal tuberculosis a spray
of silver-nitrate solution in the
strength of 3^ to 2 grains (0.03 to
0.12 Gm.) to the ounce (30 c.c.) may
be of service. Crocq claims that sil-
ver nitrate is a valuable remedy in
pulmonary tuberculosis, promoting
appetite and digestion and diminish-
ing cough, expectoration, and night-
sweats. He administers from % to
Ys grain (0.008 to 0.02 Gm.) daily, in
divided doses. It may, with advan-
tage, be given in a %-grain (0.01
Gm.) dose combined with 3 grains
(0.2 Gm.) of Dover's powder.
In pertussis Ringer advised the use
of a spray of silver-nitrate solution
(>4 to 2 grains— 0.03 to 0.3 Gm.— to
1 ounce — 30 c.c.) to relieve the vio-
lence of the cough and give the pa-
tient rest at night. The spray should
be used when the stomach is empty,
as it may bring on retching. The
nozzle of the atomizer should be
placed well within the mouth to pre-
vent staining of the skin.
In atrophic rhinitis and ozena,
Gleason obtained good results by
painting a 20 per cent, solution of
argyrol over the afifected area.
Ophthalmic Disorders. — ^^Silver ni-
trate is found useful in ophthalmolog-
ical practice in all strengths from a
1-grain (0.06 Gm.) solution to the
solid stick.
In simple conjunctivitis, where the
discharge is profuse, a 2- to 5- grain
(0.13 to 0.3 Gm.) solution is of value
In purulent, including gonococcal,
ophthalmia, when the discharge is
profuse, the lids should be everted
and wiped dry, and painted with a
10- to 15- grain (0.6 to 1 Gm.) solu-
tion of silver nitrate, immediately
neutralized with a solution of com-
mon salt. This should be done once
daily.
Protargol is more satisfactory than
either argyrol or silver nitrate for the
treatment of acute mucopurulent con-
junctivitis due to the Koch-Weeks
bacillus. Argyrol is better than sil-
ver nitrate. Protargol is perfectly
safe up to 33 per cent. Its applica-
tion causes much less pain than sil-
ver nitrate, but more than argyrol.
The solution was freely used and the
excess left in the eye. It was always
applied with small pellets of absorb-
ent cotton. Drops for home use were
always given — silver nitrate in 0.2
per cent, strength, or argyrol or
protargol in 5 per cent, solution.
Butler (Ophthalmoscope, Jan., 1907).
Many more cases of conjunctival
argyria result from the use of or-
ganic silver compounds, such as pro-
targol and argyrol, than from silver
nitrate. The writer protests against
the almost universal use of such com-
pounds in acute and chronic catarrhal
conjunctivitis. For these conditions
a collyrium containing ^ grain (0.03
Gm.) zinc sulphate and 10 to 12
grains (0.65 to 0.77 Gm.) of boric
acid to the ounce (30 c.c.) is more
surely and promptly efficacious than
the silver compounds mentioned. S.
Theobald (Johns Hopkins Hosp.
Bull, Nov., 1911).
Granular lids and trachoma are
benefited by silver nitrate. If there
is slight discharge the stick should be
used; if there is copious discharge,
the use of a 10-grain (0.6 Gm.) solu-
tion, with neutralization of excess,
once daily will be followed by
improvement.
In blepharitis, Hinshelwood recom-
SILVER (SAJOUS). 139
mends the use of argyrol, a strong upon to overcome the more severe in-
solution of which is rubbed into the fective conjunctival inflammations,
lid margins after each has been Cutaneous Disorders. — It is claimed
cleaned of crusts with a camel's-hair that pitting in smallpox may be pre-
brush cut short. This procedure is vented by puncturing the vesicles, on
applied at first daily, then every the fourth or fifth day, with a needle
second or third day. dipped into a 4 per cent, solution of
In diphtheritic conjunctivitis, after silver nitrate. Others paint the skin
the absorption of the membrane and with a 1 or 2 per cent, solution, and
the re-establishment of the discharge, claim that it is equally effective. The
one may cautiously use silver-nitrate mitigated stick has also been used,
solution as in purulent ophthalmia. Silver nitrate is also used to de-
Crede initiated the use of a 1- or stroy parasitic fungi, to cause ex-
2- per cent, solution, 1 drop in each foliation of the epidermis, or for a
eye, in the eyes of all newborn in- local stimulant effect. As a caustic
fants to prevent the occcurrence of it is inferior to several other agents.
ophthalmia neonatorum. This is, by It has been found useful in some
many, made a routine procedure, forms of eczema (chronic forms and
Where all possibility of infection of circumscribed patches), and in reliev-
the birth canal can be excluded, flush- ing the itching of prurigo and lichen.
ing out with a saturated boric acid Pruritus ani and pruritus vulvae may
solution is sufiicient. be benefited by a 4- or 6- grain (0.25
Silver nitrate cannot be used safely or 0.4 Gm.) to the ounce (30 c.c.)
in the eye in a solution stronger than solution painted upon the parts two
3 per cent. A 2 per cent, solution, to four times daily,
even if neither neutralized or washed The use of silver nitrate has
out, never causes any irritation. Any also been recommended in lupus,
solution stronger than 3 per cent., psoriasis, erythema, ringworm, and
unless at once neutralized with salt erysipelas.
solution, leaves a faint film of de- Venereal Disorders. — In the treat-
stroyed epithelium, especially in ment of buboes good results have
infants (Butler). been reported from injections of a
The use of silver should be inter- 2 per cent, solution of silver nitrate
dieted where corneal ulceration ex- in the early stage,
ists, and when continued use of a In orchitis and epididymitis a
remedy is desired. The danger of strong solution of the nitrate painted
permanently staining the tissues must over the scrotum, in the early stages,
not be forgotten. will often relieve the pain and reduce
In place of silver nitrate, protargol the swelling.
(5 to 20 per cent.) and argyrol (5 to Injections of silver-nitrate solu-
50 per cent.) are often used. Their tions are most useful in the later sub-
advantages consist essentially of less acute stages of gonococcal urethritis,
irritant power and greater ease of em- in the strength of 1 part of the salt
ployment, but their antiseptic power in 500 to 3000 parts of water, bc-
is decidedly inferior. Neither (espe- ginning with the weaker solution.
cially argyrol) should be depended Strong solutions used early have
140
SILVER (SAJOUS).
been advised for the purpose of
aborting the disease ; such use is,
however, not to be commended.
Fifty-five men, suffering from gon-
orrhea, were treated with injections
of protargol, beginning with y\ io Yz
per cent., and increasmg m stiength
to 1 per cent. The patients waslicd
the urethra out with warm water be-
fore injecting the protargol. The
protargol injections were kept at first
for ten minutes, and later up to thirty
minutes. Of the 55 patients, only 2
showed signs of irritation. The aver-
age time occupied in causing the
gonococci to disappear finally from
the discharge w-as 16.3 days.
Five children with gonorrheal vul-
vovaginitis were treated with 2 per
cent, solutions for the acute stages
and 5 per cent, for the subacute
stages. The parts were cleaned and
the solution injected into the vagina
and kept there for ten minutes, the
pelvis being raised. None of the
children complained of irritation.
Sitz baths were employed as a sup-
plementary treatment. It took on an
average of three months befoie the
last cocci were removed from the
secretion of the vagina and cervix.
Protargol yielded as good or better
results in female gonorrhea than
other means. The writer employed
it in solutions of from 5 to 10 per
cent., and met with no irritating ef-
fect. Irritant effects are probably
due to worthless imitations of pro-
targol, and at times to the solutions
not being made up freshly with cold
water. C. Stern (Deut. med. VVoch.,
Feb. 7, 1907).
The drug is also^ useful in 1 : 500 to,
1 : 5000 strength in prostatitis, sem-
inal vesiculitis (after massage), and
the cystitis of enlarged prostate, or
bladder stone or tumor.
Gynecological Disorders. — In ul-
ceration of the cervix, and in those
cases of leucorrhea in which the
cervix is boggy and tender, great
benefit may follow the application of
the solid stick within the cervix.
This procedure is frequently followed
by headache about the vertex, but
this can be relieved with 10-grain
(0.6 Gm.) doses of the bromides.
Silver-nitrate solutions were used
very extensively for erosions of the
cervix, btit other remedies have sup-
planted them. Vomiting of preg-
nancy can sometimes be relieved by
brushing the cervix over with a 60-
grain (4 Gm.) solution of the nitrate.
Removal of Silver Stains. — Silver
stains on clothing may be washed off
with a solution containing 45 grains
(3 Gm.) of potassium cyanide, 5
grains (0.3 Gm.) of iodine, and 1
ounce (30 c.c.) of water. Another
method is to dissolve 15 grains (1
Gm.) of corrosive sublimate in 7
ounces (210 c.c.) of boiled water, and
add about 45 grains (3 Gm.) of so-
dium chloride just before using; the
stained material is to be placed in it
for about five minutes and then
washed two or three times. Hahn
advises the use of a solution contain-
ing 75 grains (5 Gm.) each of corro-
sive sublimate and of ammonium
chloride dissolved in 10 drams (40
c.c.) of water.
When the stains are older they
may be rubl:)ed with a mixture of
iodine and ammonia, and the part,
still wet, then washed thoroughly.
(When dry, it is highly explosive.)
Potassium cyanide in solution will
generally remove stains from the
fingers or skin. The part should be
well rinsed immediately afterward.
Or, the skin may be covered with
tincture of iodine and then washed
off with a solution of sodium thio-
sulphate (hyposulphite).
L. T. DE M. Sajoits,
Philadelphia.
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
141
SINUSES, NASAL ACCES-
SORY; DISEASES OF.— The nasal
accessory sinuses, the maxillary, or
antrum of Highmore, the frontal,
ethmoidal and sphenoidal, are com-
monly involved in various disorders :
acute and chronic rhinitis, the vari-
ous diseases of childhood, and also in
pneumonia, influenza and typhoid
fever, through extension of the infec-
tion to them. Especially is this apt
to be the case when septal deviation,
nasal polypi, turbinate hypertrophy,
or any other condition capable of in-
terfering with proper drainage of the
nasal cavities is present. These con-
ditions may also provoke chronic in-
flammation of the sinuses, due to
accumulation in them of secretions
containing pathogenic bacteria. It
may also be caused by chronic ca-
tarrhal disorders, in which intumes-
cence of the nasal mucosa is more
or less permanent, and characterized
by mucopurulent discharge. The
source of infection may be located in
the mouth. Not only may carious
teeth awaken suppuration of the an-
trum when, as in the case of certam
bicuspids and molars, this sinus is
penetrated by the roots of teeth, but
also through germs such as the end-
ameba, pneumococcus and other or-
ganisms concerned with pyorrhea
alveolaris. Tonsillar streptococci are
also thought to prove pathogenic in
some instances. Syphilis, tubercu-
losis, carcinoma, sarcoma and other
destructive processes may also extend
to, or occur in, either of the sinuses.
Their bony framework may be in-
volved in fractures, punctured wounds
and other traumatisms.
The pathological changes induced
are characteristic. Although the mu-
cosa covering the walls of the various
sinuses is hardly one twenty-fourth of
an inch thick, inflammation with the
accompanying edema may cause it to
swell to eight or nine times this
thickness, and to become polyp-like.
The cavity becomes more or less oc-
cluded as a resonance chamber, while
the pressure exerted centrifugally by
the swollen mucosa upon its walls
may cause pain, such as that pro-
duced in the frontal sinus in the
course of influenza, in the antrum
during a local inflammation, etc. The
first mucoid secretion soon becomes
replaced by mucopus, unless arrested
in the first stage, owing to invasion
by pyogenic bacteria and phagocytes.
While this may occur in any sinus,
the frontal and maxillary sinus, or
antrum of Highmore, are the seats of
predilection for a purulent process.
Important in this connection is the
formation of fistulous openings where
the orifices of a sinus are occluded
sufficiently by the swollen mucosa to
prevent the discharge of pus. These
openings, which occur through the
thinnest and weakest portion of the
walls of the sinus, may entail severe
complications, such as orbital cellu-
litis, infection of the cranial contents,
meningitis, periostitis of the osseous,
tissues adjoining the sinuses, etc.
Disorders of the nasal accessory
sinuses, therefore, may prove danger-
ous to life if neglected.
MAXILLARY SINUS OR AN-
TRUM OF HIGHMORE.
INFLAMMATORY DISOR-
DERS.— The maxillary sinus may be
seat of acute or chronic inflammation.
Acute Inflammation. — This disor-
der may occur as an extension of
an acute rhinitis or some inflamma-
tory disorder of the anterior nares.
142
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
through the antral opening below the
middle turbinate, the invasion of
pus, irritating powders or fumes, in-
sects, foreign bodies, etc., or occur as
one of the manifestations of a gen-
eral infection or toxemia.
The main symptom is a neuralgic
pain referred to the cheek of the af-
fected side. It presents as a charac-
teristic feature that of being most
severe in the region of the malar
bone. If the nasal disorder be such
as to occlude, by swelling, the ostium
maxillare, the pain may be severe and
extend to the orbital region. The pain
may also affect the upper dental arch,
even though the teeth of the corre-
sponding area be normal, owing to
the tension in the antral cavity.
All these symptoms become ag-
gravated where the antral exudate
becomes purulent. The teeth which
bury their roots in the lower portion
of the antrum, and adjoining teeth,
give rise to severe pain on being per-
cussed. While a diseased tooth —
either the second bicuspid or first
molar — in most instances is a frequent
cause of antral sinusitis and abscess,
the determination of this fact should
be left to a competent dentist. Sound
teeth have often, been removed by
incompetent or careless operators.
' The antrum, owing to its size, is
the most prolific source of discharge
of all the sinuses. At first mucoid
and gelatinous, it eventually assumes
a mucopurulent character, and is
voided through the nasal orifice if
the latter be patent and into the
nose, and drawn thence into the naso-
pharynx and expectorated or swal-
lowed, especially if the nasal passage
of the corresponding side be ob-
structed, or if the patient is in the re-
cumbent position. If the nasal cavity
is relatively ])atent, the discharge is
voided anteriorly. It is apt to have
a foul odor if the cause of the antral
purulent process be due to diseased
teeth. When the discharge is pent
up in the cavity through blocking of
the nasal orifice a fistuluus opening is
formed unless the mucopus be arti-
ficially removed or resolution occur
spontaneously. The pus may break
through the nasal wall, forming a
fluctuating tumor in the middle
meatus, i.e., Under the middle turbi-
nate, or through the lower portion of
the anterior wall of the sinus, and
escape in the sulcus between the gum
and the cheek above the first or
second molar.
Chronic Inflammation, or Empy-
ema.— This condition results from
the acute form when it fails to dis-
appear spontaneously or remain un-
treated. The membrane then be-
comes organized, thickened, irregular
and polypoid in character, polypi
sometimes projecting through the an-
tral orifice beneath the middle turbi-
nate. In most cases, however, this
orifice remains patent, and gives pas-
sage to a free discharge which is
found in this location, i.e., the middle
meatus, the elimination of which, an-
teriorly or posteriorly, is subject to
the same conditions as in acute sinu-
sitis. Exacerbations of discharge oc-
cur along with temporary catarrhal
symptoms. At times the mucopus
eliminated is very fetid and imparts
its fetor to the patient's breath. But
little, if any, pain is complained of,
and general phenomena, fever, etc.,
are seldom observed.
Although some cases may undergo
spontaneous resolution, the majority
persist sluggishly during many years,
undergoing periodical exacerbations
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
143
of activity. These may occur after
apparent cure through appropriate
measures, so that in all cases the
prognosis should be guarded.
The diagnosis of antral inflamma-
tion is not difficult when the location
of the pain, the presence of pus in the
middle meatus, and marked sensitive-
ness of the teeth immediately beneath
the antrum can be discovered. In
most cases, however, transillumina-
tion— a strong electric light being
placed in the mouth— should be used,
'showing as it does obstruction to
light on the diseased side as com-
pared with the relative free illumina-
tion on the normal side. It affords,
at least, corroborative testimony.
When both antra are diseased, an ex-
ploratory puncture of the suspected
antrum beneath the inferior turbinate,
under local anesthesia, may be re-
sorted to, but only under strict anti-
septic precautions. In marked cases
empyema may be recognized after
carefully spraying out the nose, by
causing the patient to bend his head
over to one side, when a marked ac-
cumulation of purulent exudation will
appear in the uppermost nostril. Per-
cussing the cheek and the teeth may
elicit suggestive pain.
The writer questions the efficacy
of transillumination as the deciding
factor in determining antral suppura-
tion, and places more dependence
upon the suction syringe for diag-
nostic purposes. The specially de-
vised needle is readily inserted, and
nearly a syringeful of water is quickly
injected into the cavity of the an-
trum, and at once sucked back into
the syringe, in order to obtain a
specimen of the antral contents. In
a number of cases the writer's sus-
picions of antral suppuration were
negatived by excellent transillumina-
tion, with pupil reflex, whereas, the
use of the syringe revealed the pres-
ence of thick pus in greater or less
amount, or the existence of plugs of
mucus with or without pus. Wil-
liams (Jour, of Laryn., Rhin., and
OtoL, Mar., 1912).
When from any cause, the nasal
opening of the antrum becomes oc-
cluded— through swelling of the nasal
membrane, polypi, plug of purulent
material, diphtheritic membrane, etc.
— all the symptoms, especially the
pain and swelling, become progres-
sively worse. The pain finally be-
comes intense, while the swelling in-
cludes bulging of all neighboring
parts, the cheek, palate, gums and
teeth, eyeball. Symptoms of pyemia,
chills, sweats, and high fever also ap-
pear. Thinning of the walls of the
sinus progresses, however, and finally
rupture occurs either tlyough the
palate, alveolar process, orbit or nasal
cavity. As soon as the pus is evacu-
ated in this manner all the symptoms
disappear, apart from those of the
remainine chronic inflammation de-
scribed above, and a more or less
permanent fistula.
In an examination of 100 heads in
the necropsy room, the writer found
that 37 per cent, showed some evi-
dence of pathological changes in the
maxillary antra. Of these 37 cases,
11 were examples of edema; 12 were
examples of chronic inflammation or
empyema; 1 was an example of an
alveolar or dental cyst, and 13 were
examples of retention cyst. With
one or two exceptions, all of these
cases were undiagnosed during life.
The presence of a large amount of
pus in 10 out of 12 of these cases of
empyema may have played an active
part in causing the death of the pa-
tients. J. P. Tunis (Laryngoscope,
Oct., 1910).
TREATMENT,— In all the phases
of antral inflammation careful atten-
144 SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
tion should be given to the nasal In mild or incipient cases due solely
cavity. Acute cases and exacerba- to the presence of an inflammatory
tions of activity in chronic cases may disorder in the cavities, this mild
often be checked if seen early when treatment, if persisted in, sufifices to
a nasal inflammatory disorder is the check the antral trouble. It should
cause, by thorough cleansing with be remembered that polypi, hyper-
warm saline solution, used freely with trophy of the middle and inferior tur-
a coarse atomizer, followed by the binal, a foreign body, etc., may prove
local application, with a' pledget of to be the exciting cause, and that ap-
cotton on a nasal probe, of the gly- propriate treatment of these condi-
cerite of iodotannin, which is pre- tions is necessary,
pared as follows: — The teeth, the roots of which pro-
B lodi Sss (2 Gm.). ject into the sinus from below, being
Acidi tannici ,Sss (15 Gm). occasionally the source of antral in-
^^^ Oss (250 c.c). flammation, they should be carefully
M. Filter and evaporate to Bij (62 c.c.) examined. Mere sensitiveness un-
and add i . ,
„, . cler percussion does not warrant a
Glycerini fjiv (125 c.c.) . i ■ . i . i i
J' .. ow y o c.c.;. conclusion that they are the source of
This solution is applied freely over trouble, since inflammation of nasal
the nasal mucosa, and particularly origin may also cause neuralgia in the
under the middle turbinate, the area upper dental arch. Teeth should only
forming the middle meatus into which be drawn, therefore, after an X-ray
the orifice of the antrum opens. If the bas clearly shown them to be the
tissues are sw^ollen, the application of cause of the antral disorder. Since
the above should be preceded by a the recognition of the fact that pyor-
spray of 4 per cent, solution of co- ibea alveolaris is present in most per-
caine to contract it and anesthetize it. sons after the thirtieth year, espe-
This treatment should be carried out cially in view of the resistance of the
by the physician daily. The patient Endamcba buccalis, a communication
should then be shown how to use between the mouth and the antrum
drops into the nose in such a way as should be avoided when at all pos-
to cause them to bathe the outer wall, sible. It is probable, in fact, that the
including the space under the middle persistence of empyema treated in
turbinate, i.e., by bending his head this manner and necessitating a per-
well over on side of the sinusitis. He manent tube or plug in the alveolar
should then be ordered to spray his perforation is due to constant reinfec-
nose carefully night and morning with tion by gingival organisms. When,
saline solution to cleanse it, then to therefore, the exciting cause is clearly
apply 5 or 6 drops of 1 : 5000 solution traced to a tooth and it becomes nec-
of adrenalin into the nostril of the essary to extract the latter to irrigate
afifected side, and after a few minutes the sinus, it is best to pack the open-
follow this up with a spray of the i^g with iodoform gauze, and to re-
following oily solution: — peat the irrigations a few times. If
Camphor, this does not suffice to cure the antral
Menthol aa gr. j (0.06 Gm.). disorder — which it often does in re-
Benzoinol l\] (62 c.c). cent cases — it is preferable to allow
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
145
the alveolar openingf to close and to
create an opening through the nasal
wall.
The alveolar operation should never
be done as an operation of choice,
because it establishes a communica-
tion between the mouth and a sup-
purating cavity, and requires the use
of a tube or plug, which is decidedly
disadvantageous. The open method
of doing the canine fossa operation
is likewise to be condemned on much
the same grounds. When simple
irrigation has failed or is not prac-
ticable, the next step should be a
large opening in the inferior meatus,
with removal of a portion of the
inferior turbinate. If this method is
employed, very few patients will
require radical operations. Wells
(Laryngoscope, Dec, 1906).
Having encountered a case of fatal
bleeding in entering the antrum with
a sharp trocar through the inferior
nasal meatus, as well as occasional
infections of the pterygomaxillary
fossa from excessive momentum of
the instrument and accidents from
entrance of the point of the trocar
into an orbital cell, the writer deter-
mined to discard the sharp-pointed
trocar for a smooth-tipped rasp mod-
elled after those used by Vacher and
by Watson Williams for penetrating
into the frontal sinuses. An opening
large enough to facilitate irrigation
and avoid premature closure is thus
made. Luc (Rev. de laryng., d'Otol.
et de rhinol.. May 15, 1918).
Although the ostium maxillare is
most easily reached and penetrated,
its situation, in the middle meatus,
i.e., under the middle turbinate, would
cause a trocar to enter the antrum
too high up to permit of effective
drainage through the nose. It is
preferable, therefore, to puncture the
thin wall of the antrum which faces
tlie area beneath the inferior turbi-
nate. A pledget of cotton well-moist-
ened, a 10 per cent, solution of
cocaine having been placed in this
location and left there about ten min-
utes, a Coakley or Myles trocar and
cannula, sterilized by boiling, is in-
troduced upward and outward under
the inferior turbinate until one inch
of the instrument from the lower edge
of the nostril has entered the nose.
The trocar is then pushed in through
the wall into the antrum, then with-
drawn, leaving the cannula in situ.
Through it the antrum can be
drained, then washed out by means
of syringe with saline solution, and
again drained dry — a measure which
often suffices in recent or mild acute
cases to effect a cure.
Efforts must be chiefly directed to
promoting the free and spontaneous
discharge of pus from the antrum by
way of the natural ostium, by: (a)
directing the patient to lie in bed
with the diseased antrum uppermost;
(b) the application of cocaine and
adrenalin solutions to the regions
around the middle meatus — this may
be done every four or six hours; (c)
scarification of these regions; and
(d) inhalation of mentholized steam.
If these means fail the antrum should
be punctured through its inner wall
in the inferior meatus, and irrigated.
Tilley (Brit. Med. Jour., Aug. 22,
1908).
It should be borne in mind, how-
ever, that the anatomical relations of
the frontal and ethmoidal cells with
the antrum render the latter a sort of
receptacle for discharges from the
former. When all these structures
are diseased, therefore, drainage of
the antrum in the manner described
is useful in several ways.
In those cases in which the entire
chain of cells is diseased — the an-
trum, the ethmoidal cells, the frontal
sinus, and in many cases the sphe-
noidal sinus also — Jansen has pro-
posed the extensive external opera-
8—10
146
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
tion of laying open the entire chain.
This operation is only called for and
only warranted in extreme cases in
which the cavities are the seat of
myxomatous or other growths. In
all ordinary cases of empyema of the
antrum and ethmoidal cells, asso-
ciated with nothing more than a de-
generated condition of the mucous
membrane that has resulted from a
prolonged maceration in pus, these
external operations are, in the opin-
ion of the writer, unnecessary, for
the reason that diseased conditions
of the maxillary sinuses, and also of
the ethmoidal cells, which are com-
monly associated with an empyema,
can be successfully treated by the
nasal route. J. O. Roe (Annals of
Otol., Rhin., and Laryn., June, 1909).
It is sometimes necessary, owing to
the necessity of keeping the artificial
opening patent for continued drain-
age and local treatment, to enlarge
the opening. This necessitates re-
moval of the lower anterior portion
of the inferior turbinate. Wells's op-
eration is much used for this purpose.
In this procedure the anterior half of
the inferior turbinate is first removed
under local anesthesia with a 10 per
cent, solution of cocaine and ischemia
with 1 : 5000 solution of adrenalin by
means of serrated scissors and the
snare. An opening is then made with
a trocar, as explained above, but
lower down and close to the floor of
the nose. This opening is then en-
larged by means of a rasp, used in
such a way as to extend the opening
anteriorly, following the line of the
nasal floor until the junction of the
nasoantral with the facial wall of the
antrum is reached.
Skillern's operation obviates the
necessity of resecting a portion of the
inferior turbinate. It is performed
as follows : After cleansing the nasal
cavities, anesthesia is secured by the
application f)f a 20 per cent, solution
of cocaine and l)y injections of novo-
caine and adrenalin. A s])indle-shaped
piece of mucous meml)rane is re-
moved in front of the inferior tur-
l)inate by two incisions extending
through all tlie tissues to the bone,
and the crista pyriformis is exposed.
With a chisel, forceps and an electric
trephine the antrum is then opened,
flushed out, inspected, curetted, and
packed loosely with iodoform gauze.
The gauze is removed in forty-eight
to seventy-two hours and replaced
every second day for two weeks.
This operation enables the operator
to inspect directly the sinus and to
follow dc visu local applications to
any part of the diseased area, includ-
ing some that are usually resistant
to treatment.
In acute maxillary sinusitis one
should irrigate the cavity as sug-
gested for empyema; this failing, it
may be necessary to make a wide
artificial opening in the lower part
of the nasoantral wall for ventila-
tion. In chronic maxillary sinusitis
one should make a wide artificial
opening in the nasoantral wall; this
failing, one should expose the sinus
through the facial wall, and curette
the interior. Wells (Med. Rec, Oct.
29, 1910).
We have seen that inflammation of
the mucosa of sinuses causes it to
thicken greatly and to form polypoid
projections. In the presence of pus
this thickened mucosa becomes a
soggy mass which requires the con-
servative use of the curette — not the
vigorous curetting which the late
John O. Roe has very properly con-
demned— the snare for polypoid
masses, and the application of reme-
dies to all parts of the diseased cav-
ity. This can only be done by means
of an operation which enables the
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS). 147
operator to reach the sinus through procedure Ly his experience in op-
the mouth and nose. Such a pro- ^''^ting by the Luc-Caldwell method,
, , .1 i-> u 11 T when he frequently found a mass of
cedure, known as the Caldwell-JLuc , . ^. • ,, n r ,u
granulation tissue in the floor of the
operation, is begun in the mouth l)y ^^trum which often led to an abscess
means of an incision in the sulcus be- about the apex of a tooth. A. R.
tween the gum and lip above the Solenberger (Colo. Med., xii, 269,
bicuspid and first molar. The perios- 1915).
teum being detached up to the infra- TUMORS OF THE MAXILLARY
orbital canal, an opening is drilled SINUS, OR ANTRUM.
into the antrum as starting for re- Polypi. — The tumors most fre-
moval, by means of rongeur forceps quently found in the antrum are
and chisel, of the greater portion of polypi, which, as stated above, often
the anterior wall of the sinus, forming occur in cases of empyema of long-
a gap through which the index finger standing. They may either develop
may easily be introduced. Through in the antrum itself or project out of
the oroantral opening thus made a the antrum into the nose and develop
disk of bone about one-half inch in under the middle turl)inate.
diameter is removed from the nasal Cysts. — These are of two kinds,
wall, including the anterior half of The one, developed from the mucosa
the inferior turbinate. of the antrum, gives rise to period-
Besides permitting any curetting or ical discharges of a. watery, odorless
snaring that may be necessary, this fluid, and, when sufficiently large, to
operation affords a free field for local deformity and' bulging of the affected
treatment. Irrigations with saline side.
solution, followed by insufflations of The second variety arises from an
iodoform over all parts of diseased alveolus, and is due to cystic degen-
surface, a-nd packing with iodoform eration of the peridental membrane.
gauze daily for ,a week or ten days, It causes erosion of the antral wall,
will usually deal effectively with a penetrates the antrum by pushing its
case of empyema. The oroantral open- mucosa before it, then grows rapidly,
ing may be closed by sutures after soon filling the cavity, and causing
free drainage and the use of the cu- deformity of the face and palate on
rette or snare, and the medical treat- the corresponding side. A character-
ment carried on through the nasal istic crackling sensation is elicited by
opening. At times stimulation of the compressing its outer wall. If it
antral membrane is necessary; this ruptures it yields a greenish, thick,
may be done by using a spray of 25 odorless fluid, containing, as a rule,
per cent, solution of argyrol. Irritant cholesterin crystals. Unlike the other
antiseptics and astringents are more variety, there is no discharge in the
harmful than beneficial in antral nasal cavity, unless it ruj^tures, when,
diseases. becoming infected, it simulates an
Removal of a tooth, unless it can empyema, giving- off a fetid discharge,
be demonstrated to be the^ offending Osteoma'!— In this form of tumor.
member, is bad practice. The author ^ i t i i
, , .... svmptoms are only awakened when
advocates an examination through a - '
sufficiently large opening in tlic an- the neoplasm has grown sufficiently
terior wall. He was led to adopt this to compress the uasal wall, and thus
148
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
gradually decrease the lumen of the
nasal passage of the correspondintj
side. No pain is experienced until a
large size is attained, and no dis-
charge of an abnormal character is
complained of. An exploratory needle
or trocar thrust into the tumor is ar-
rested as soon as the mucosa is pene-
trated, and transillumination shows
complete darkness as compared with
the other side.
Malignant Tumors. — Sarcoma and
osteosarcoma are the growths most
commonly observed in the antrum.
Cases of psamnio- sarcoma, epithelioma,
perithelioma (Sakai) and endothelioma
have been reported. These tumors,
particularly sarcoma, grow with rela-
tive rapidity and usually cause lan-
cinating pain and considerable swell-
ing. After filling the antrum, they
penetrate into the nasal or naso-
pharyngeal cavity, rapidly decreasing
their lumen and giving rise to a mu-
copurulent discharge often streaked
with blood and detritus, and giving
off a foul odor. The glands behind
the angle of the jaws are enlarged
soon after the nasal cavities are
invaded.
Unique case, as a careful search of
medical literature revealed none like
it, of a calculus made up almost
entirely of a calcium phosphate and
found in the course of an operation
for a squamous-celled epithelioma
involving the antrum of Highmore.
N. H. Carson (Interstate Med. Jour.,
Mar., 1913).
TREATMENT.— The removal of
polypi from the antrum requires, as
previously stated, sufficient room to
render the use of the curette or snare
possible. For this purpose the Cald-
well-Luc operation affords the re-
quired room. This applies also to the
removal of ordinary cysts. As regards
the cysts of dental origin an injection
of a 2 per cent, solution of phenic acid
into the cyst, through an incision
above the diseased tooth if necessary,
causes shrinking and disappearance.
If the growth cannot be reached, the
Caldwell-Luc buccal opening should
be practised, and the cyst removed,
including the offending tooth, if
necessary.
Osteomata can only be removed sat-
isfactorily by dissecting up the facial
tissues from the antral wall and by
means of chisel and gouge insure
complete excision of the growth.
This operation, which should, of
course, be done under general anes-
thesia, is but rarely followed by
recurrence. In malignant growths re-
moval of the affected superior maxilla
alone affords any hope of recovery.
FRONTAL SINUS.
INFLAMMATORY DISOR-
DERS.— The frontal sinus may be
the seat of acute and of chronic
inflammation.
Acute Inflammation. — In this con-
dition, especially when suppuration is
present, there is more or less severe
pain between and above the eyebrows,
which presents the characteristic of
being increased by leaning forward
and by coughing and of being so ag-
gravated on blowing the nose that the
patient is apt to avoid emptying the
nasal cavity properly. Percussion
over the sinus also causes pain ; this
is likewise the case when pressure is
exerted under the frontal sinus, i.e.,
on the orbital plate below the edge
of the orbit under the supraorbital
foramen. The whole superciliary re-
gion, especially over the course of the
supraorbital nerves, is hyperesthetic.
In mild cases a sensation of fullness
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
149
and weight in the frontal region is
alone experienced. The discharge, at
first serous, may become bright yellow
and purulent, and pass down into
the nasal cavity between the middle
turbinate and the outer wall of the
cavity, but if the orifice, the infun-
dibulum, be obstructed, the sinus is
distended, and a fistulous opening
may form, or the abscess may break
into and invade the neighboring an-
terior ethmoidal cells.
CHRONIC INFLAMMATION.—
Chronic inflammation of the frontal
sinus may occur as a result of acute
inflammation of the sinus, or, through
extension, a chronic ethmoiditis, in
which the anterior ethmoidal cells are
ruptured through distention and allow
their purulent contents to penetrate
into the frontal sinus. An antral em-
pyema may also act as primary cause.
The antral mucosa undergoes poly-
poid thickening, and sometimes be-
comes the source of polypi which
project into the nasal cavity and
cause considerable annoyance. In
most cases but little pain is com-
plained of, a sensation of fullness or
pressure above the brow, and some
tenderness over the latter, being usu-
ally experienced. Swelling or bulg-
ing over the frontal sinus may also
occur. There is, in most cases, con-
. siderable discharge which may be
voided anteriorly or posteriorly, the
patient complaining that he is suffer-
ing from "nasal catarrh." Periodical
discharges of mucoserous or muco-
purulent fluid may afford considerable
relief.
Pent up, the discharge may cause
rupture of the sinus and pass into the
orbit, the nasal cavity, the dura
mater, causing meningitis ; or the
lymphatics may serve as carriers of
pathogenic bacteria or purulent ma-
terials to the meninges. Edema and
redness of the upper eyelid is usually
present. Fistulous openings may also
form anteriorly, i.e., through the an-
terior wall of the sinus, opening above
the inner canthus. The pain, when the
suppuration is confined in the latter,
is severe and constant, and often as-
sumes a neuralgic or boring charac-
ter. Or, persistent headache with
insomnia may occur. The frontal re-
gion becomes markedly bulged, and
in extreme cases one or both eyeballs
may be displaced, causing diplopia.
Even amaurosis has been caused
through persistent pressure upon the
eyeball. Systemic phenomena, sug-
gesting pyemia chills, sweats, fever,
etc., are often observed in severe
cases. Persistent pressure may so
reduce the thickness of the anterior
walls as to make it possible some-
times to obtain fluctuation and crack-
ling. Unless the pent-up discharge
be removed surgically, rupture may
occur and awaken the dangerous com-
plications recited above.
The presence of a frontal abscess
is not definitely shown by trans-
illumination. An X-ray photograph
affords a clear idea of the topography
of the sinus, the diseased side appear-
ing relatively dark. If the same area
also appears dark under transillumi-
nation, the diagnosis of local disease
is correspondingly strong. This is
further strengthened if, on examining
the nasal cavity, pus or polypi are
found beneath the middle turbinate
into which the infundibulum, the
elongated outlet of the frontal sinus,
opens.
TREATMENT. — An important
feature of acute frontal sinusitis is
that it is apt to develop in conjunc-
150
SINUSES, xNASAL ACCESSORY; DISEASES OF (SAJOUS).
tion with the acute rhinitis attending
various febrile disorders. In influ-
enza, for instance, the pain aljout the
brow is due to this cause. The local
process is simply that of occlusion of
the infundibulum, through swelling
of its mucosa. The escape of the
mucus to the nasal cavity being pre-
vented, distention of the sinus and
swelling of its mucosa follow, giving
rise to the painful sensation. The
aim should be, therefore, to free the
sinus by opening it. This may be
done with a spray of warm saline
solution directed upward under the
middle turbinal. A 2 per cent, solu-
tion of cocaine, containing 2 drams (8
c.c.) of the 1 : 1000 solution of adrena-
lin to the ounce (30 c.c.) is then
sprayed in the same region, the pa-
tient leaning fonvard while using the
spray in order to cause the fluid to
flow into the infundibulum. After a
few minutes, considerable relief will
be experienced, owing to contraction
of the tissues around the infundib-
ulum, and a flow of mucus will soon
follow. Repeated every two hours,
this procedure will prevent suffering,
unless polypi or hypertrophies pre-
vent access of the remedial fluid to
the frontal passage.
In a number of acute cases marked
relief was obtained — because of the
free rhinorrhea set up — from the in-
tranasal use of the following solu-
tion: Mercuric iodide, 1 Gm. (15
grains); potassium iodide, 4 Gm. (1
dram), and water, 100 c.c. (iVs
ounces). D. Macfarlan (Jour. Amer.
Med. Assoc, Jan. 3, 1914).
The patient should be kept at rest
and placed on a light diet, avoiding
stimulants, coffee, etc.. to keep the
blood-pressure within its normal
limits. Drugs, such as opium, bella-
donna, etc., which tend to cause dry-
ness of the mucous membranes,
should be avoided. Saline purgatives
should be used if ihc bowels are not
free. The biniodide of mercury in
^20-grain (0.003 Gm.) doses three
times daily shortens the purulent
process by enhancing the antitoxic
.'uid bactericidal properties of the
blood. Hexamethylenamine, 4 grains
(0.26 Gm. ) three times daily, has
been recommended.
The same local treatment some-
times proves useful in chronic cases,
when used four times daily, the
fourth time on retiring, giving also
the biniodide of mercury. If it fails,
the frontal sinus cannula should he
introduced into the sinus, and the
frontal sinus washed out daily with
saline solution, the patient being
taught to use the cannula and to
wash out the sinus also on retiring.
In most cases the cannula is easily
introduced by passing its curved tip
upward under the anterior end of the
middle turbinate. When this does
not suffice to insure proper drainage
and restore the sinus to its normal
condition, removal of anterior portion
of the middle turbinate with cutting
forceps is indicated. This provides
free access to the sinus for local treat-
ment by injection of 20 to 30 minims
(1.25 to 1.8 c.c.) of a 10 per cent,
solution of argyrol after careful wash-
ing with the warm saline solution.
When these less radical methods
prove insufficient for proper drainage,
opening of the sinus through its an-
terior or inferior wall becomes neces-
sary. When this is done, enough of
the wall must be removed to permit
a thorough examination of the cav-
ity and enlargement of the naso-
frontal duct to an extent sufficient
for free drainage into the nose. If
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
151
operation is delayed too long, the
continued pressure may cause rup-
ture through the floor into the orbit
or through the posterior wall of the
sinus into the brain-cavity, with con-
sequent purulent meningitis or brain
abscess.
The surgical treatment of frontp-
ethmoidal sinusitis has progressed
through many ch.nges. To cure
frontal sinusitis and prevent its re-
currence it is necessary to eradicate
the cavity. The ethmoid is approached
by the endonasal route so that when
the frontal sinus is opened all that
remains to be done is to enlarge the
nasofrontal canal at the level of the
infundibular region for free drainage.
The modification of the Ogsten-Luc
operation is less mutilating and fur-
nishes excellent drainage. A rather
large bony opening is made at the
level of the frontal boss in order that
the whole frontal cavity may be in-
spected and curetted completely. E.
J. Moure (Laryng., xxxi, 479, 1921).
Such operations should be per-
formed only by a highly trained
specialist, as otherwise they are
fraught with danger.
The indications for the external
operation of the frontal sinus may
be divided into absolute and relative.
Absolute indications are: (1) Where
the disease has made such progress
as to seriously threaten some neigh-
boring organ, and even life itself is
threatened, or there are actual cere-
bral and orbital complications. (2)
When the subjective symptoms are
severe enough to interfere with the
business pursuits of the patient. (3)
When severe exacerbations occur.
(4) In abscess or fistula formation.
Relative indications are: (1) When
the headache continues with no ap-
parent change in the amount or con-
sistency of the secretion. (2) When
despite frequent irrigations the pus
continues fetid, even though dimin-
ishing slightly in amount. (3) When
the X-ray shows a large sinus with
many ramifications and the disease
does not appear to yield satisfactorily
to internal treatments.
As to the type of operation, this
is often determined by the patholog-
ical change present or the anatom-
ical configuration of the sinus. Other
things being equal, the writer per-
forms his modification of the Jansen
operation, in which he can spare the
anterior wall, but obtain the requisite
space. This is done by resecting the
superior internal portion of the mar-
gin of the orbit and the floor of the
sinus, thus exposing the entire lower
portion or funnel of the frontal sinus.
After this has been done the usual
procedures are followed, i.e., removal
of diseased mucosa, the ethmoid cells,
and, if necessary, the sphenoid is
opened. The communication with
^the nose may be enlarged to any
desired size by merely removing the
orbital plate piecemeal with the bone
forceps. The wound is closed and
dressed in the usual manner. R. H.
Skillern (Laryngoscope, xxv, 212,
1915).
The writer believes that the exter-
nal (Killian) operation on the frontal
sinus has not fulfilled the brilliant
hopes that were raised at the time
of its introduction, and that the ear-
lier successes reported have been
discounted by instances of septic
osteomyelitis, an almost universally
fatal complication, even in the hands
of skillful operators. In many cases
very grave deformity has resulted,
and, in addition, the operation often
fails to give the relief sought.
Intranasal methods for obtaining
drainage and space for lavage by the
removal of the anterior end of the
middle turbinate have long been
practised and are of value, but are
often, also, insufficient to effect a
cure. To Ingals is due the credit of
introducing the method of following
up the frontonasal duct and entering
the sinus through the normal ostium.
All subsequent intranasal methods
are developments of the Ingals op-
eration. The author believes most of
these to be dangerous, and advances
152
SINUSES, XASAL ACCESSORY; DISEASES OF (SAJOUS).
his own operation as being compara-
tively safe. He begins lielow and an-
terior to the middle turbinate and
continues upward to the frontal
sinus, "without destroying any part
of the vertical plate of the ethmoid,"
a point he thinks of much impor-
tancCj since he says it does not in-
volve fracturing through the vertical
plate in close proximity to the crib-
riform plate and laying open venules
and lymphatics in this dangerous
area to infection. The writer's op-
eration may be done with cocaine,
but he much prefers general anesthe-
sia. His technique is simply to cut
through the most anterior attach-
ment of the middle turbinate with a
conchotome and continue biting up-
ward through the anterior cells to
the crista nasalis. In the same man-
ner the cells lying behind the duct
are then removed to any necessary
extent. Sounds are passed into the
sinus and all projecting edges re-
moved. Often this will suffice, but
if enough room has not been secured
by these measures, the nasal crest
may be rasped away, but it is much
preferable to use a guarded burr for
this purpose. The advantage claimed
for the burr is that the mucous mem-
brane of the posterior wall is left
intact and the bone only laid bare
anteriorly.
He advocates the use of from 30
to 50 c.c. of polyvalent antistrepto-
coccus serum immediately before the
operation, followed by the adminis-
tration of sensitized vaccines. Sounds
should also be passed at regular in-
tervals after the operation to insure
the permanency of the opening made.
Over one hundred frontal sinuses
have been treated in this way by the
author, who claims that many have
been cured and nearly all relieved.
In a few instances he was unable to
reach the sinus pernasally. P. Wat-
son-Williams (Surg., Gynec. and Ob-
stet., from Lancet, July 15, 1915).
As stated by Shurly some years
ago, the surgery of the frontal sinus
will become more conservative as
our knowledge grows. The relief
should come, not through surgery
alone, but from prophylaxis and the
successful abortion of the common
colds. An important feature of these
cases is tlie careful treatment of
chronic rhinitis in any of its forms
(see Nose, Diseases of, in the sev-
enth volume). A change to a semi-
tropical climate, such as that of
I'lorida or Southern California, pref-
erably near the seashore, sometimes
proves curative.
TUMORS OF THE FRONTAL
SINUS.
Mucocele. — Mucoceles are but re-
tention cysts formed by closure of
the infundibulum and the accumula-
tion of the exudate within the sinus.
This gives rise to a feeling of disten-
tion and neuralgic pain in the supra-
orbital region, which is itself exceed-
ingly sensitive to palpation. In some
instances there is formed a polyp-
like tumor of the swollen mucosa
which is visible under rhinoscopic
examination if a very small mirror be
used, and sufficient often to form a
myxoma-like tumor under the middle
turbinate. In others, the pressure is
also exerted anteriorly or laterally
and by eroding the orbital wall
causes displacement of the eyeball.
Case of an unusually large muco-
cele of the frontal and ethmoidal
cells. The patient, a woman 69 years
of age, was first examined November
25, 1914, for a supposed growth of
the left orbit. There were two lumps
the size of beans just below the
brow, which coalesced and formed a
marked prominence, displacing the
eye outward and downward. There
was no pain or evidence of inflam-
mation, nor any appreciable derange-
ment of vision. She gave a history
of having had nasal catarrh several
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
153
years before, but had not been trou-
bled since. Uncorrected vision was
5/7.5 in the right, 5/9 in the left. The
fields of vision were normal. The
proptosis of the left eye was about
1.5 cm. in advance of the right.
The periocular swelling eventually
reached the size of a hen's egg and
was systic to the touch. The rhino-
logical examination showed a large
cystic mass that had apparently de-
stroyed the orbital wall of the frontal
sinus. The left nasal fossa was free,
although the lateral wall seemed
more prominent than usual in the
agger nasi region. Transillumination
of the antrum was negative. The
X-ray report was that the supra-or-
bital ridge was completely absorbed
and the sinus enlarged upward on
the frontal bone.
An external operation was per-
formed with the incision through the
brow and the sac exposed, the walls
of which were found to be composed
of thickened periosteum, which was
filled with the frontal sinus contents.
The bone of the anterior wall and
floor of the sinus had entirely eroded
away, and the ethmoid cells were
exposed on the removal of this sac.
These were partially exenterated and
drainage established into the nose.
The posterior wall was also eroded
and the meninges were separated
from the sinus only by the perios-
teum. Healing was prompt and with-
out incident. In two weeks the
wound was closed and the excursions
of the eye were normal. Uncorrected
vision was now 5/7.5 in each eye. W.
C. Posey (Ophthal. Rec, xxiv, 116,
1915).
Cysts. — Cysts similar to those ob-
served in the maxillary sinus have
occasionally been observed in the
frontal sinus. They contain a green-
ish or brownish viscid fluid, some-
times v^^ax-like, which is voided with
difficulty when they rupture. A very
gradual swelling, accompanied by lit-
tle or no pain about the brow, is
about the only symptom noted, even
though the osseous walls of the cyst
are being thinned by pressure until
palpation and slight compression im-
parts a crackling, parchment-like sen-
sation to the finger.
Case of a cyst of the frontal sinus
in a man of 56. The tumar had been
growing fifteen years, the patient
having refused operation until it
measured 38 by 35 cm. An incision
released 1800 Gm. of a reddish
brownish fluid. The brain was found
much compressed, while the bone
had been worn away. The case is
remarkable from the absence of
brain symptoms and of pain or other
sensation except the discomfort from
the large tumor, although after its
removal there was room for the fist
between the skull and the brain.
Herzenberg (Deut. med. Woch., Nov.
4, 1909).
Osteoma. — Primary osteoma of the
frontal sinus is rarely encountered.
It grows very slowly, and finally pro-
duces considerable deformity of the
face. At first the growth is insidious,
but after a time neuralgia becomes a
leading symptom, with, perhaps, un-
due sensitiveness over the growth ;
however, even under pressure, the
latter conveys to the finger a sen-
sation of flinty hardness. Trans-
illumination shows darkness on the
affected side, but the growth is sel-
dom sufficiently circumscribed to en-
dow this diagnostic resource with
much value. An X-ray plate affords
aid only within the same limitation.
Case of osteomalacia in a married
woman, aged 35, who had been op-
erated on fifteen years previously.
The main orbital projection had been
removed, with marked relief to the
orbital symptoms. The patient con-
sulted the writer because of severe
pain, obstruction of the right nos-
tril, and gradual protrusion of the
right eyeball. The radiograph gave
most valuable information as to the
154
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
position and extent of the exostosis.
A curved incision was made from the
middle of the right ej^ebrow to the
right ala nasi. The expanded and
thinned covering of bone was clipped
off, and, the pedicle of the growth
attached to the posterosuperior wall
of the frontal sinus having been di-
vided, the whole growth was re-
moved with comparative ease by-
means of a strong pair of forceps.
The growth measured 2^ inches in
length and 1J4 inches in breadth.
The wound healed by first intention.
Jones (Brit. Med. Jour., Nov. 17,
1906).
In examining the frontal sinus, an-
trum and ethmoidal cells, the writer
takes first a lateral view of the face,
and, secondly, an anteroposterior pic-
ture with the tube behind the head
and the plate in front. Anteropos-
terior pictures of the head seldom
show as well in print as in the orig-
inal print or negative, which is best
examined by transmitted light in a
negative examining box. Tousey (N.
Y. Med. Jour., Mar. 28, 1908).
Malignant Tumors. — Although all
forms of malignant growths in this
location have been recorded, epithe-
lioma and sarcoma are those most fre-
quently observed. The symptoms
being practically those of chronic
sinusitis, empyema, and mucocele, an
early diagnosis is difficult. Even the
advanced signs, such as prominence
of the eyeball with diplopia, amauro-
sis and pain, are common to other
disorders. Suggestive; however, is a
more or less foul discharge from the
nose when it is streaked with blood
and detritus, and traced with pre-
cision to the infundibulum, or, in the
case of sarcoma, recurrent hemor-
rhages, traced to the same region.
Swollen glands behind the angle of
the jaw may suggest malignancy.
TREATMENT. — Mucoceles' and
cysts can sometimes be opened in the
nasal cavity and its contents evacu-
ated. This is facilitated by causing
constriction of the surrounding tis-
sues by means of a 4 per cent, solu-
tion of cocaine, followed by spraying
with saline solution. In most cases,
however, the contents are gelatinous
and cannot be evacuated without an
incision over the projecting wall, re-
secting a sufficient portion to allow
curetting and packing with iodoform
gauze.
Osteomata require enucleation;
malignant growths likewise, if seen
in time. Unfortunately, their prog-
ress is insidious and, as a rule, they
are not recognized early enough to
permit successful operative measures.
ETHMOID CELLS.
INFLAMMATORY DISOR-
DERS.— The ethmoid cells may he
the seat of acute and of chronic
inflammation.
Acute Inflammation; Acute Eth-
moiditis. — The proximity of the an-
terior ethmoidal cells to the frontal
?nd maxillary sinus exposes them to
involvement by contamination, while
the posterior cells are exposed to it
from the sphenoidal cells. Its con-
n.ection with the nasal cavity exposes
the ethmoidal sinus to the catarrhal
■disorders and to occlusion, nasal
growths, swellings, etc. Being itself,
besides, liable to inflammatory disor-
ders, this sinus is probably more fre-
quently diseased than is generally
supposed, and the underlying seat of
many stubborn cases of chronic
rhinitis.
The symptoms of acute ethmoiditis
are not always clearly defined. The
pain is usually referred to the orow
and behind the eyes, but sometimes
only persistent headache is com-
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
155
plained of. The discharge of the an-
terior cells follows the same course
as those of the antrum and frontal
sinus, its elimination, anteriorly or
posteriorly, if the nasal cavities are
free, depending upon whether the
head is bent forward or backward.
Hence the fact that the nasopharynx
often contains accumulated discharge
in the morning after a night in the
recumbent position. The acute form,
which occurs as a complication of ar
acute rhinitis or a temporary con-
tamination from a neighboring in-
flammatory process, disappears when
the latter ceases, unless imperfect
drainage prevents it.
Chronic Inflammation or Chronic
Ethmoiditis. — In this disorder the
inflammatory process initiated by a
similar process in the neighboring
sinuses or the nose persists. In one
form, the hyperplastic, the mucosa is
swollen and gives rise to a watery
discharge which is irritating to the
nose, the aire, and upper lip. There
is severe boring pain either in the
supraorbital region, suggesting neu-
ralgia, or at the root of the nose,
radiating toward the temples. There
may be a sensation of pressure in the
eyes, muscse volitantes, and also an-
osmia. The pharynx, larynx, Eustach-
ian tubes, and middle ear may be
involved in the inflammatory process.
Asthma is sometimes witnessed in
these cases. Acute exacerbations are
common, a feature which leads to
atrophy of the muciparous glands,
atrophy, and even sclerosis. The se-
cretion may then become scanty and
form a tenacious mass which dries
and forms foul-smelling crusts.
The second form, suppurative eth-
moiditis, dififers from the former, in
that the discharge is purulent instead
of merely watery. It may be caused
by many morbid condition^ : adjoin-
ing catarrhal disorders, imperfect
drainage, syphilis, tuberculosis, ery-
sipelas, influenza, and other infec-
tions, fractures, operative trauma-
tisms, etc. In most cases met with,
however, obstruction of the outlet of
the cells beneath the middle turbinate
is a prominent cause. This may be
due to the viscidity of the discharge,
or, as is often the case, to mechanical
obstruction in the middle turbinate
or of the septum, either through
osseous malformation or hypertro-
phy of their mucosa.
An important feature of this disor-
der is that, owing to the thinness of
the partition walls, these break down
easily and necrose, giving rise to a
foul discharge. In a large proportion
of cases there is merely a copious
purulent outflow, voided through the
nose or nasopharynx, the latter of
which it reaches from the superior or
middle meatus. The pus may be
sanious, contain bits of necrosed tis-
sues and other detritus, and give off
a more or less offensive odor. Pain
is rarely observed in the chronic
form, but a sensation of marked dry-
ness may cause considerable discom-
fort.
If retention of the pus in the cells
occurs through obstruction of their
lumina, serious symptoms may be de-
veloped, such as congestion, edema,
bulging of and pressure in eyeballs,
sometimes entailing diplopia and
even blindness in neglected cases.
Systemic disturbances, suggesting py-
emia, may occur. Mental disorders
and meningitis may also supervene if
the pus invades the cranial cavity — a
not uncommon complication, which
often proves rapidly fatal. Cerebral
156
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
abscess and thrombosis of the caver-
nous sinus, from infection of the
ethmoidal veins, may also occur.
Fortunately, the most usual result is
rupture, with formation of a fistula
leading externally to and opening be-
low the brow, over the inner angle of
the eye. The pus is thus eliminated
externally.
The diagnosis of acute inflamma-
tion of the ethmoidal cells should be
based upon careful examination of the
nasal cavities. The above-described
symptoms are all observed in inflam-
mation of other disorders. Sugges-
tive in this connection, however, is
redness of the lower edge of the mid-
dle turbinate and extending beneath it.
In the chronic form, a purulent dis-
charge may be observed in this loca-
tion coursing down along the external
wall of the nose, and backward over
the inclined surface of the inferior
turbinate.
Latent sinusitis of the ethmoidal
sinus may be the underlying cause
of certain reflex neuroses. A simple
operation on the sinus in such cases
frees the patient from his "neuras-
thenia," "Meniere's disease," "hay
fever," "nervous rhinorrhca" or other
similar complaints. Menkes (Nederl.
Tijdsch. V. Geneesk., Apr. 12, 1919).
Treatment. — Acute inflammation
of the ethmoidal cells is mainly per-
petuated by obstruction of their out-
let. The treatment recommended for
acute inflammation of the frontal
sinus in this section is also indicated
here. In chronic inflammation the
causative rhinitis, septal or turbinal
malformation interfering with the
drainage of the cells must be cor-
rected. The measures indicated un-
der Chronic Rhinitis (see page 72
in the seventh volume) will prove
very efficient. Local applications of
a 20 per cent, solution of argyrol,
after cleansing the nasal cavity, in-
cluding the middle meatus, with
warm saline solution is highly bene-
ficial. This weak solution of argyrol
may also be used with an atomizer
provided with an upward tip, which
may be passed under the middle tur-
binate. If a stronger solution (50
per cent.) is used, the applicator is
preferable. Ichthiol and strong solu-
tions of silver nitrate, which some-
times are necessary, should only be
used with the applicator. The possi-
bility of involvement of the neighbor-
ing sinuses should always be borne
in mind and adequate treatment car-
ried out if needed.
The antrum often acts as a reser-
voir for the pus originating in the
ethmoidal or frontal cells, and hence
efforts to cure an antrum abscess,
without first curing the ethmoidal or
frontal sinus abscess, prove futile,
while, converse!}', the curing of the
. latter will usually result in cure of
the antrum disease without any at-
tention being directed to the antrum
itself. Todd (Jour. Minn. State Med.
Assoc, and N. W. Lancet, Oct. 1,
1911).
When medication does not suffice,
owing to obstruction ofifered by the
middle turbinate to the drainage of
the cells, the anterior portion, or in
severe cases the whole turbinate,
should be removed. By placing the
diseased cells within reach of the
remedies, and insuring efficient drain-
age and ventilation, this procedure
often suffices. When this does not
suffice, the ethmoid cells must be
opened by means of Hajek's curved
hook, and enlarged with Griinwald's
forceps. Saline solution irrigations
mav then be used to wash out the
cells, and a 10 per cent, argyrol spray
to promote resolution, which often
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
157
occurs. If it does not, and necrosed
bone be found, Bryan's ethmoid cu-
rette should be used to remove it
while continuing the irrigations.
Considerable care is necessary in this
operative procedure to keep within
the limits of the cells, as penetration
of the cribriform plate above, or of
the external cellular walls, may en-
tail serious complications, and even
death.
The writer reports 2 fatal cases of
suppurative ethmoiditis in children,
and concludes that there is an in-
creasing conviction that acute sup-
purative ethmoiditis causing orbital
and cerebral symptoms is not so
rare a condition as has been thought,
and that it is often rapidly fatal,
especially in the young. The indi-
cations for operation in acute eth-
moiditis are sudden increase in tem-
perature, delirium at night, tumor
formation in the inner wall of the
orbit, the slightest exophthalmos.
Operation should not be delayed too
long. As in appendicitis, early op-
eration is a harmless procedure, late
operation generally useless.
When there is bilateral exophthal-
mos, operation is generally useless,
as the disease has probably extended
through the cavernous and circular
sinuses, causing a general toxemia
and pyemia, or fatal brain lesion.
Krauss (N. Y. Med. Jour., Apr. 24,
1909).
If it is the wish of the operator to
clean out all the ethmoidal cells, the
posterior half of the labyrinth is en-
tered by piercing the attachment of
the middle turbinate and by curetting
still farther backward, using all the
while the outer side of the middle
turbinate as a guide. If the head of
the patient is held level, the middle
turbinate guides the curette back-
ward into the posterior ethmoidal
cell. Often the posterior half of the
labyrinth is a large cavity, made up
of only one or two cells. This por-
tion of the labyrinth has been, as it
were, exenterated by nature. When
the curette brings up against the
back wall of the labyrinth the re-
maining part of the middle turbinate
and the lower half of the superior
turbinate are removed. Then the
posterior part of the superior turbi-
nate is taken away, flush with the
front face of the sphenoidal sinus.
The operator now recognizes the
inner part of the front face of the
sphenoidal sinus, which is free in the
nasal cavity, and the outer part which
has a common wall with the pos-
terior ethmoidal cell. The posterior
outer upper angle of the posterior
ethmoidal cell is dangerous to cu-
rette or to probe. It is of the utmost
importance that the operator should
be sure of his landmarks in this lo-
cality. He orientates himself by find-
ing the upper rim of the choana and
then differentiating the free face of
the sphenoidal sinus by proceeding
upward from the rim of the choana
close to the septum. Having made
out the extent of the free face of the
sinus, the width of the common wall
between the sphenoidal sinus and the
posterior ethmoidal cell is deter-
mined. The dividing line between
the two parts of the anterior face
of the sphenoidal sinus is made by
the obliquely vertical line, which is
the attachment of the superior tur-
binate.
The usual mistake made by the
operator is to get lost in the pos-
terior ethmoidal cell — that is, he goes
too high and too far outward, and
considers the posterior wall of the
posterior ethmoidal cell as the whole
of the front face of the sphenoidal
sinus. This mistake, if persisted in,
will carry him into the brain. In-
sufficient removal of the posterior
part of the superior turbinate and
allowing the head to become tipped
upward, are the chief causes of this
confusion. After the landmarks of
the front face 'of the sphenoidal sinus
have been cleared and recognized, the
sinus is entered near the septum — if
possilile, through the ostium — and
the whole of the anterior wall re-
158
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
moved. II. P. Mosher (Laryngo-
scope, Sept., 1913).
Non-operative treatment of infected
sinuses, a suction apparatus being
substituted, advised. The author has
obtained entirely satisfactory results
and has discarded oi)erative work, ex-
cept on the antrum. Illustrative re-
ports of successfully treated cases in-
clude instances of severe acute fron-
tal sinusitis; acute suppurative of the
anterior ethmoid cells with orbital
abscess; acute suppuration of the
right frontal sinus; chronic suppura-
tion of the frontal sinus, anterior
ethmoid cells, and antrum; chronic
suppuration of the left frontal sinus,
and chronic suppuration of the pos-
terior ethmoids and sphenoids. E. B.
Gleason (Laryngoscope, 18, 1, 1918).
TUMORS OF THE ETHMOIDAL
CELLS.
Benign Tumors. — Mucocele of the
ethmoidal, irrespective of involve-
ment of the other sinuses, is occa-
sionally met with. It may occur as
a result of chronic ethmoiditis, espe-
cially when the ostium is occluded, or
of blocking of some of the glandular
acini. The tumor may fill the cell
in which it is formed, break down
the thin walls between the cells, or
project out of the ostium and appear
under the middle turbinate. Myxoma,
osteoma, fibroma, and other benign
growths may also occur in this loca-
tion. All the growths develop in-
sidiously, and cause no pain, until, in
some instances, nerves are com-
pressed, extended, or affected reflexly,
or the neoplasm encroaches seri-
ously upon neighboring structures
and deforms them. In some cases
other sinuses are penetrated by the
growth which erodes the walls,
separating them.
Case of a lady who had been an-
noyed for several months by a very
profuse serous discharge from the
right nostril when she stooped. This
discharge was found to escape from
a small opening in the top of carious
bone in tlic wall of the bulla eth-
moidalis. The dividing walls of the
ethmoid cells had all been destroyed,
making one cavity of the lateral mass
of the ethmoid bone. This cavity
was hned by a thin, white, glistening
membrane, the typical cyst lining in
appearnce. This membrane was cu-
retted lightly, the cavity was packed
for twenty-four hours to control
hemorrhage, and then removed. A
month later it was reported that the
only change was that the discharge
was now continuous, whereas for-
merly it had taken place only upon
stooping. Inspection of the nose
showed a free opening into the cyst
with fully two-thirds of the cavity
covered with normal membrane. Six
weeks later the patient reported en-
tirely well. Thompson (Laryngo-
scope, Mar., 1911).
Malignant Tumors. — Sarcoma and
epithelioma of the ethmoidal cells is
occasionally observed as a primary
process. In epithelioma the growth
may be very insidious and be discov-
ered only when stifficiently advanced
to cause nasal obstruction, when ex-
amination reveals its presence. A
fetid discharge streaked with blood
and detritus and enlargement of the
glands behind the maxillary bone are
suggestive. Sarcoma usually pro-
gresses more rapidly, and is apt to be
attended with free and, sometimes,
dangerous hemorrhages.
TREATMENT.— Surgical removal
is alone of value. Malignant growths
have often progressed sufficiently to
involve many surrounding structures
when first seen — a fact which greatly
compromises the chances of recovery.
Case in a man, aged 55 years, who
was unable to breathe through the
right nasal passage, but without any
other symptom of distress. The pas-
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
159
sage was found filled with cauliflower
excrescences which bled at the slight-
est contact with the probe. Poste-
rior rhinoscopy revealed pretty much
the same aspect, and digital explora-
tion detected a soft vegetative mass
covering the rhinopharynx, the right
choana, and reaching from the roof
to the soft palate, barely passing the
middle line, and consequently leav-
ing a free space upon the right side.
On diaphanoscopy, the frontal maxil-
lary sinuses became illuminated nor-
mally. The mass was removed by
external access with a good deal
of hemorrhage, necessitating several
tamponings. The middle and the su-
perior turbinates were destroyed, the
anterior ethmoidal cells resected to
the cribriform plate of the ethmoid,
and the septum was resected in its
posterior portion. Every suspicious
surface was thoroughly curetted, and
hemorrhage arrested by tamponing
the nasal fossse with iodoform gauze,
and the skin wound united with su-
tures. Recovery was good. Fifteen
months later the patient still breathed
freely, and his nasal fossa did not
exhibit any trace of the growth.
Audibert (Revue Hebd. de Laryn.,
d'Otol. et de Rhin., Feb. 24, 1912).
SPHENOIDAL SINUS.
INFLAMMATORY DISOR-
DERS.— The sphenoidal cells may be
the seat of acute and of chronic
inflammation.
Acute Inflammation. — Acute in-
flammation of the sphenoidal sinus
may occur as an extension of a
similar process in the neighboring
sinus, or the nasal and nasopharyn-
geal cavities. It is identified with
difficulty; the symptoms — a dull,
deep-seated headache, referred by
some patients to the occipital region,
and by others to "somewhere behind
the eyes" — constitute about all the
subjective symptoms which suggest
this disorder. Inspissated mucus, ac-
cumulated in the postnasal space, to
the exclusion of the anterior nasal
cavities, and voided, as a rule, is an-
other suggestive fact. In some cases
these symptoms persist and consti-
tute a mild "postnasal catarrh." In
others, they disappear spontaneously.
Chronic inflammation or empyema
of the sphenoidal sinus may be due to
infection by neighboring purulent
process in the other sinuses or nasal
cavities, or syphilis, tuberculosis, or
fractures of the base involving the
sphenoid. Besides the symptoms ob-
served in the acute form, neuralgia
throughout the distribution of the
fifth pair may be experienced, tinni-
tus and vertigo likewise. The dis-
charge, instead of mucoid, is now
mucopurulent and fetid, and tends to
accumulate about the posterior end
of the middle turbinate, and to pass
down into the nasopharynx. When
swallowed, especially if other sinuses
are afifected, which is often the case,
gastric disturbances and nausea may
be caused.
When obstruction of the sphenoidal
orifice occurs, the symptoms in-
crease greatly in severity, severe
pain, insomnia, a febrile reaction oc-
curring promptly. Extension of the
inflammatory process to the brain is
sometimes observed. As the disten-
tion increases, ocular phenomena ap-
pear, which may include congestion
of the conjunctiva, swelling of the
lids, and even amaurosis, owing to
compression of the optic nerve. The
swelling may block the posterior
choane and cause violent aural symp-
toms. Rupture may occur into the
ethmoidal cells, the orbit, or the
skull, and cause, in the latter case,
rapidly fatal meningitis.
The diagnosis of sphenoidal em-
160
SINUSES, NASAL ACCESSORY; DISEASES OF (SAJOUS).
pyema is based mainly upon the
simultaneous presence of a persistent
discharge into the posterior nares,
traced above the vault area, and pain
in the back of the head, after exclud-
ing tlie other sinuses.
The writer has devised an instru-
ment which can be introduced into
the pharynx by way of the mouth
and which carries a miniature plate,
so that this can be brought into con-
tact with the wall of the sphenoid.
By X-ray illumination through the
frontal region of the cranium from
above, an accurate picture can be ob-
tained of the sphenoidal sinuses. The
method is simple and yields valuable
information regarding this region
hitherto so difficult to photograph.
Bela Freystadtl (Berl. khn. Woch.,
July 13, 1914).
TREATMENT. — The treatment
of intiammatory disorders is, in the
main, similar to that of other sinuses
reviewed. After applying a 10 per
cent, solution of cocaine to the space
between the middle turbinate and the
septum, which will contract not only
the tissues of these structures, but
also those around the sphenoidal open-
ing, a sphenoidal cannula is passed
into the latter, and the cavity washed
out with saline solution. Irrigation
cannot be done sometimes without
creating an opening in the most de-
pendent portion of the sinus by
means of a gouge passed along the
surface of the middle turbinate,
p)ointing the instrument upward and
backward, under posterior rhinoscopy.
Too big an opening by allowing the
escape of a large quantity of pus to
escape may cause syncope, hence a
small opening is preferable at first.
The curette is sometimes necessary,
followed by saline solution irriga-
tions and the local application of a
10 per cent, solution of argyrol.
Although it is not necessary to
have the ostium in view in passing
a sound, to the author's mind it is
absolutely demanded when operative
measures are about to be undertaken;
the anatomic relations of the superior
wall to the optic nerve and the pitui-
tary body and the lateral walls to
the sinus cavernosus and carotid ar-
tery, to say nothing of the brain it-
self, makes this region of operating
one of extreme danger, unless the
operator has perfect vision of the
entire field. The lateral wall of the
nose, as well as the septum, is co-
cainized with a 20 per cent, solution,
the posterior half of the middle
turbinate is removed, the posterior
ethmoid cells are broken through
with Hajek's ethmoid hook, and the
debris removed with a Griinwald-
Hartmann conchotome or a similar
instrument. The evulsor is then in-
serted in the ostium and the opening
enlarged by a few well-directed pulls;
this is followed by the use of the
bent forceps of Hajek and enough
bone is removed as to insure a per-
manent opening, which should reach
as far as the floor of the nose. Com-
plete healing usually takes place in
from three to eight weeks, depend-
ing on the degree of inflammation
and the extent of the operative inter-
ference. The advantages of this op-
eration is that a full field is always
in sight; the preliminary opening of
the sphenoid from within outward
thereby incurs no danger to the
structures behind; and there is a
permanent opening which lessens the
danger of recurrence. Ross H. Skil-
lern (Jour. Amer. Med. Assoc, Dec.
19, 1908).
The writer anesthetizes the nose
with cocaine and epinephrin, and
punctures the anterior wall of the
sinus at its lower and internal por-
tion. In the absence of any obstruc-
tive deformity of the upper part of
the septum nasi this can be readily
accomplished in the vast majority of
cases, and no removal of nasal tissue
is necessary. This opening has the
SKIN-GRAFTING (FREEMAN).
161
further advantage of being in the
best position for drainage of the cav-
ity. The operation is free alike from
pain, hemorrhage, and danger. If the
cavity is normal the wound will have
closed in twenty-four hours. If the
sinus is infected the operation affords
the best possible opportunity for
making an early and accurate diag-
nosis and for the employment of
suitable measures for local treatment,
particularly lavage and drainage. C.
P. Grayson (Penna. Med. Jour., Apr.,
1913).
TUMORS OF THE SPHENOIDAL
SINUS.
Benign Tumors. — Myxomata and
osteomata, occasionally found in this
sinus, are harmful mainly because
they tend early to produce obstruc-
tion, and, therefore, bring- on em-
pyema. As the tumor grows it brings
on pressure symptoms, blindness or
optic neuritis, when the optic nerve
is compressed; exophthalmos of the
eyeball, etc.
Malignant Growths.— These pro-
duce phenomena similar to those just
described when they have progressed
sufficiently to do so. A purulent san-
guinolent discharge in the vault,
traced upward to the sphenoidal
opening, is about the only early sign
availal)le.
TREATMENT.— The location of
the sphenoid renders operative re-
moval impracticable, especially in
view of the fact that the cases are
usually far advanced when they
reach the specialist.
C. E. DE M. Sajous,
Philadelphia.
SKIN-GRAFTING. -When skin
grafts are obtained from the patient
himself, they are called autografts;
when from another person, homo-
grafts; and when from animals, coo-
gra'ffs. The best results are derived
from autografts. Homografts grow
better than zoografts, but it must not
be forgotten that they may cause dis-
ease, especially syphilis, and that they
may break down and disappear upon
slight provocation.
Reverdin's Method.— With fresh
wounds or healthy granulating sur-
faces little preparation is necessary.
Freedom from suppuration would, of
course, be desirable, but it is seldom
attainable. When the granulations
are not in good condition an effort
should be made to render them firm,
red and healthy by pressure, by re-
peated cauterization with stick nitrate
of silver, or by painting them occa-
sionally with tincture of iodine. Leg
ulcers may often be much improved
by elevation of the extremity. Cal-
lous ulcers should have radiating in-
cisions made in their borders. Foul
ulcers must receive preliminary anti-
septic treatment, and all sloughs •
should be cleared away before graft-
ing is attempted.
The grafts, which are best obtained
from the arm or thigh, should be
about the size of a grain of wheat.
They are cut by elevating a portion
of skin with mouse-toothed forceps
and dividing it with scissors curved
on the flat, removing the entire epi-
thelium and a portion of the corium
without disturln'ng the subcutaneous
fat. The bits of cuticle adhere to the
surface to be grafted, especially if
gentle i)ressure with a pledget of
gauze be employed. Nothing is
gained by scraping or m any way
wounding the granulations. The
transplantations should be close to-
gether, as the greatest size to which
a graft can grow is perhaps that of
a silver dime. Excellent grafts can
11
162
SKIN-GRAFTING (FREEMAN).
be cut with sharp-pointed scissors
from the delicate pellicle of new skin
which pushes out from the borders
of a healing ulcer (Souchon). Imme-
diately over the grafts may be placed
strips of rubber protective, or a single
layer of gauze, which may be pinned
around a limb or fastened at the
edges with collodion. Whether the
external dressing is moist or dry is
usuall}^ of little importance, but no
antiseptic stronger than boric acid
should be used. As there is gener-
ally some suppuration, it is necessary
to change the superficial portion of
the dressing every twenty-four hours
at least, leaving in place the rubber
tissue, or the undermost layer of
gauze, as the case may be. Gentle
irrigation with a solution of salt or
boric acid assists in maintaining
cleanliness. The open method of
dressing has recently come into use,
and may often be employed to ad-
vantage. In this the grafts are left
entirely uncovered, being protected
from injury by placing over them a
"cage" made of wire gauze (a kitchen
"strainer" for instance). The edges
of the gauze are bound with adhesive
plaster, a few strips of which may be
utilized to hold the cage in position.
Thiersch's Method. — There is no
process of skin-grafting so simple, so
reliable, and so generally applicable
as this. It is of great value in the
treatment of ulcers, burns, and de-
fects following operations or injuries.
The patient is anesthetized, and if
granulations are present, it is best to
scrape them away with a sharp spoon
down to the comparatively firm tissue
beneath, although this is not abso-
lutely necessary. Oozing is checked
by elevation and pressure, an Es-
march strap being unnecessary. The
grafts are cut with a razor from the
anterior surface of the thigh or upper
arm. An assistant makes the skin
tense by means of a hand on either
side of the limb, while the operator,
standing with his back toward the
patient's feet, cuts toward himself,
with his left hand stretching the tis-
sues in the direction of the knee.
With a backward and forward saw-
ing motion it is not difficult to obtain
shavings of epidermis an inch or
more wide and several inches in
length, and as thin as paper: No
objectionable scar results. The deli-
cate strips of cuticle fold up on the
blade of the razor, from which they
may be spread directly upon the sur-
face to be grafted, and so adjusted
that they overlap each other and the
edges of the skin, completely con-
cealing the raw surface. Healing
without suppuration is not uncom-
mon. Over the transplanted cuticle
are placed strips of rubber tissue, a
single layer of gauze, or simply a
wire cage as described in the Rever-
din method. Davis uses a coarse-
meshed net, such as is used for cur-
tains, for "splinting" the grafts in
position. The stiffening is washed
out and the net is soaked in gutta-
percha 30 parts, chloroform 150 parts,
and is sterilized by keeping in a
1 : 1000 solution of mercury bichloride.
If a moist dressing is employed, it
should consist of a thick pad of gauze
saturated with normal salt solution
and covered with cotton and oiled
silk. This should be renewed often
enough to keep it moist. A dry
dressing answers equally well, ap-
plied as in the treatment of ordinary
wounds. The grafts do not become
firmly fixed for nine or ten days, and
it is well not to soak off the under-
SKIN-GRAFTING (FREEMAN). 163
most layer of gauze for about two is unfavorable for their existence. In
weeks. five to seven days the granulations
The Wolfe-Krause Method, — In are cut from above and the grafts
this method grafts are employed exposed.
which fill the entire defect, and which In caterpillar grafting, which really
comprise the whole thickness of skin belongs to plastic surgery rather than
without the subcutaneous tissues, to skin-grafting, a long, narrow, full-
The fat may also be included if de- thickness flap (about 1 inch by 5
sired, although the chance of success inches) is dissected up from the ad-
is less (Hirschberg). In cutting the jacent integument with its base close
skin at least one-third must be al- to the area to be grafted. The distal
lowed for shrinkage. Sutures are extremity is then stitched close to the
usually unnecessary and artificial heat base, thus humping the flap up in its
is detrimental. center, much as a caterpillar crawls.
Wolfe's original method has been After union of the tip has taken place
modified and the technique improved in this position, the base is loosened
by Krause, who employs spindle- and the flap straightened out upon
shaped grafts, so that the wound the granulating surface. The oc-
produced by their removal may be casions are not numerous, however,
sutured immediately. The pieces of in which this "crawling" procedure
skin, cut into smaller pieces, if desir- is preferable to free grafting,
able, are accurately fitted into the Subcutaneous Skin-grafting. — Un-
defect which is to be closed. The der ordinary circumstances skin-
operation must be a "dry" one, and grafts cannot be used beneath the
the raw surfaces of the skin should surface of the body owing to the
be handled as little as possible. danger of infection. Rehn has dem-
Skin-periosteum-bone grafts are onstrated, however, that this can be
sometimes employed. They are cut done with more or less success by
out bodily, from the tibial region, for shaving off the superficial portion of
instance, without disturbing the con- the transplant, thus mechanically re-
nections of the component parts to moving the bacteria. Grafts of this
each other. character have been employed as a
Two curious methods of skin-graft- substitute for lost tendons, to close
ing introduced by MacLennan should the pylorus, etc., but it would seem
be mentioned, although they are sel- that less complicated methods are
dom employed. They are known as preferable, such as the use of fascia
"tunnel grafting" and "caterpillar lata,
grafting." Anomalies in Grafting. — Trans-
In tunnel grafting small grafts are plantation of the mucous membrane
slipped beneath the granulations into may be made. It may be shaved off
little "tunnels" made for the purpose, as in skin-grafting, — for instance,
where they are surrounded by ])l()od- from the lips, — or it may be stripped
clot and protected from external in- off in its entirety.
jury, which is supposed to facilitate More or less satisfactory results
their growth under certain conditions, can be obtained by the use of shav-
especially where the granular surface ings of callus from the palms of the
164 SKIN-GRAFTING (FREEMAN).
hands or soles of the feet, or from comes in time movable, but that pro-
sections of corns. "Epithelial rods" duced from Reverdin grafts remains
from warts have been successfully immovable, owing- to cicatricial tissue
used, as have also flakes of old, dried between the individual bits of cuticle.
epidermis from various parts of the Hairs may remain where transplanta-
body; even "epithelial dust" scraped tions of the entire thickness of the
from the surface of the skin will skin are made, but they are apt to
often grow on a granulating wound, become deformed or fall out. But
Deeper scrapings, drawing sufficient little postoperative contraction takes
blood to form a paste which may be place in the Thiersch and Wolfe-
spread upon a raw surface, are said Krause methods, but in the method
to be quite satisfactory at times of Reverdin contraction is apt to be
(Mangoldt). considerable. Exfoliation of epider-
Grafting from dead bodies or from mis may occur in any form of graft-
amputated limbs has frequently been ing, but this does not necessarily
resorted to, but the chance of success mean that the grafts are dead. A
is not great, and the danger of carry- remarkable phenomenon in connec-
ing disease cannot be disregarded. tion with Thiersch grafting is the
Sponge-grafting is now seldom em- readiness with which depressions fill
ployed. Very thin slices of sponge up to a level with the surrounding
are sterilized by boiling, and placed skin.
upon the raw surface. The material In plastic work about the face it
acts as a framework only for the should always be borne in mind that
granulations, and is soon absorbed. flaps of skin from the vicinity, for
The idea of grafting from animals instance from the neck, are preferable
is attractive, but the results are too to free grafts, especially the thinner
uncertain, and the method has largely ones, because their color and con-
fallen into disuse. Skin has been sistency will conform more nearly to
obtained from frogs (abdomen), that of their surroundings, thus ren-
chickens (beneath the wings), pigs, dering them far less conspicuous,
dogs, cats, rabbits, guinea-pigs. etc. COMPARISON OF METHODS.
Cocks' wattles, sections of the testi- — The simplest is that of Reverdin,
cles of rabbits, amniotic membrane, although the new skin is often little
and the lining membrane of eggs better than scar-tissue. It should be
have also been employed. reserved for cases where the rapid
HISTOLOGY AND PATHOL- closure of a granulating surface is
OGY. — The existence of epithelial desired without reference to anything
grafts may be said to be, for a time, else. Thiersch grafting has a wider
parasitic. In the course of about range of applicability than anv other
eighteen hours vascular connections method, and its results are uniformly
begin to form, firm adherence taking good, both functionally and cosmetic-
place by the tenth day. Successful ally ; but it must give way to the
grafts soon become pinkish in color. Wolfe-Krause process when thicker
New skin arising from large grafts, skin is desired, which more closely
which cover the entire raw surface resembles the surrounding integu-
(Thiersch and Wolfe grafts), be- ment. It may sometimes be expedi-
SKIN, SURGICAL DISEASES OF.
165
ent to graft from dead bodies or from
amputated limbs; and occasionally
use may be found for "epidermal
scrapings," or for epidermis obtained
from warts, corns, callosities, blisters,
etc., but one must not expect the
results to be brilliant.
The skin of animals does not com-
pare in vitality with that taken from
a patient's own body, or even from
some other person. It is seldom
necessary to transplant from mucous
membrane, as ordinary Thiersch
grafting answers the same purpose in
nearly all cases.
Leonard Freeman,
Denver.
SKIN, SURGICAL DISEASES
OF.— SEBACEOUS CYSTS, or WENS.
— A wen (steatoma) is a cystic tumor
varying in size from a millet-seed to an
orange, formed by the retention of secre-
tion in a sebaceous gland, and situated
in the skin or subcutaneous structures.
Wens occur most frequently on the scalp,
face, back, and scrotum, and may be
single or multiple. The contents of these
tumors are milky or cheesy in character,
but if the tumor be injured, inflammation
and ulceration may follow, or in the aged
the tumor may acquire a malignant char-
acter, degenerating into epithelioma.
Treatment. — A cure will be effected by
making an incision in the skin down to
the cyst and carefully dissecting it out.
Incision and mere evacuation of the con-
tents are always followed by a return of
the tumor.
FURUNCLE. — Furuncle (furunculus ;
boil) is a local inflammatory affection of
the skin, commonly involving a cutane-
ous gland or hair-follicle. They may oc
single or multiple, and may appear in
"crops."
The diagnosis of the affection is usu-
ally quite easy. It may sometimes be
confounded with carbuncle. General ap-
pearance, single opening, and circum-
scribed character usually distinguish the
boil.
Etiology. — Improper diet and hygiene,
nervous depression, overwork, too free
indulgence in greasy foods and gravies,
and irregular action of the bowels, local
irritation, friction, and prolonged poultic-
ing predispose to this affection. The en-
trance of pus-cocci into the skin is the
essential or exciting cause of this dis-
order. Single boils are usually the result
of local irritation; their appearance in
successive crops (furunculosis) is usually
an indication of impaired health.
Treatment. — Removal of the cause and
regulation of the diet claim first attention.
Open-air exercise and tonics are useful in
debilitated sul)jects. Strong ammonia,
caustic potash, acid mercury nitrate, and
other forms of caustic have been used to
abort in the early stage. Yeast, nuclein,
quinine, and mineral acids have been
given to prevent recurrence. Arsenic,
with or without iron, is sometimes bene-
ficial. Sodium sulphite or thiosulphate
(IS to 30 grains — 1 to 2 Gm.— every three
hours), calx sulphurata (% grain — 0.008
Gm. — every two or three hours), or sul-
phur may be given internally. A solution
of boric acid or of sublimate, a 10 per
cent, salicylic acid ointment, or a mix-
ture of equal parts of ichthyol and col-
lodion may be applied locally. White has
used full doses of mercury bichloride in-
ternallj' to prevent recurrence.
Hypodermic antiseptic injections into
the very base of a boil or carbuncle, early
in its history, are practically an unfailing
means for aborting an attack.
Heat is directly injurious to the mi-
crobes of furunculosis; active hyperemia
is induced, and the skin sterilized; the
profuse sweating induced prevents rapid
increase of temperature in the deeper
tissues. The hot air is first applied
around the circumference of the affected
part, and then to the boil itself. Two or
three applications are given on the first
day, and one daily afterward. Temper-
ature of air, 250° F. (120° C.).
CARBUNCLE.— Definition.— Carbuncle
(carbunculus; it is erroneously called
benignant anthrax, or anthrax") is a hard,
circumscribed, deep-seated, painful inflam-
mation of the subcutaneous tissue, ac-
companied by chill, fever, and constitu-
tional disturbance, and attended almost
166
SKIN, SURGICAL DISEASES OF.
always with circumscribed suppuration
and the formation of a slough.
Symptoms. — The local symptoms are
heat and aching, with throbbing and great
tenderness, which are often followed by
pain and redness along the lymphatics of
the part and pain and swelling in the
nearest lymphatic glands. There is at
first a chill, followed by a febrile move-
ment, which is generally well marked,
and often very severe. The constitu-
tional symptoms resemble those of ery-
sipelas very closelj^ and may be as se-
vere as those of the severest forms of
that disease, and the consequences may
be fully as grave and fatal.
Diagnosis, — The size of the inflamed
area, flatness- of surface, multiple open-
ings or points of suppuration and exten-
sive slough differentiate carbuncle from
furuncle. Carbuncle is single, furuncle
generally multiple.
Etiology. — A lowered vitality from any
cause predisposes to this affection. It is
especially common in diabetes. Microbic
infection is the exciting cause.
Prognosis. — Carbuncle is especially dan-
gerous when located on the scalp, abdo-
men, and upper lip; in these locations it
is apt to occur in young people, and
usually runs an acute course and, as a rule,
is fatal from pj-emia. The prognosis is
grave when extensive and attacking the
elderly, especially if complicated with
Bright's disease or diabetes. The prog-
nosis should always be guarded, even in
the most hopeful cases. Death is not in-
frequent in the old and debilitated.
Treatment. — General tonics, like quinine
and iron, with large amounts of nourish-
ing food, are indicated. Opium or other
anodynes may be required to relieve pain
and procure rest. Stimulants should be
given only when required.
Reynolds advises dilute sulphuric acid
in 20- to 30- minim (1.3 to 2 c.c.) doses in
2 ounces (60 c.c.) of water every four
hours (small doses are useless), with 5
per cent, carbolized petrolatum locally.
In the early stage 10 to 20 minims
(0.6 to 1.3 c.c.) of a 5 or 10 per cent,
solution of phenol in glycerin may be in-
jected into the central portion of the mass
with the view of aborting the mischief.
If seen later, firm compression by straps
hi adhesive plaster applied concentrically
may be made, leaving the central orifice
free for the discharge of sloughs and ap-
plying an antiseptic dressing over the
straps.
Another plan, applicable in the early
or late stage as well: Place patient un-
der an anesthetic; freeze the parts to
make them friable; make one long in-
cision or several crucial incisions through
the mass; remove all sloughs and decay-
ing tissue with a sharp curette; disinfect,
drain, and suture, as in an incised wound.
Another method of treatment is the
application of warm, moist, antiseptic
dressings, covered with thin rubber cloth
or oiled silk, removing sloughs as soon
as loosened, and using iodoform, aristol,
europhen, or similar antiseptic powder
freely. The use of poultices is harmful
and should be avoided.
The use of autogenous vaccine, once a
week in dose of 100 to 200 million dead
cocci was effectual. Bier's passive hyper-
emia by means of band around lower part
of the neck was used with success in
carbuncles of the face and high up on
neck. Mild constriction was sufficient for
twenty to twenty-two hours daily unless
edema appeared.
Ichthyol is practically a specific in the
treatment of carbuncles, applied pure, so
as to cover the entire swelling, except the
apex. The apex on which the ichthyol
is absent is covered with a piece of cloth
greased with tallow. The application is
renewed once a day. After three appli-
cations the surface should be washed
thoroughly so as to remove the varnish-
like coating which the ichthyol forms on
drj'ing, and a new application is to be
made.
Personal experience in the local treat-
ment of carbuncle with liquid air has
shown A. Campbell White that this is by
far the best form of treatment. It is less
painful to the patient than any other form
of treatment. Only one application is
necessary. In the treatment by liquid
air the spray is used, first projecting it
into the openings and using the air quite
freely; then quite thoroughly freezing the
external surface, which must be well
cleansed of discharge resulting from
sending air inside the carbuncle before
SKIN, SURGICAL DISEASES OF.
167
freezing. After freezing the carbuncle
should be dressed with a dry absorbent
dressing. The reaction from freezing
takes place in about twenty minutes, and
it is to this extreme hyperemia that the
success of liquid air in the treat-
ment of this affection is attributed
more particularly.
KERATOSIS SENILIS.— This affec-
tion is a cornification of the skin of old
people, general or partial, circumscribed
or diffuse, and often limited to the face
and the dorsal surfaces of the hands and
feet, or sometimes the forearm and chest.
The lesions consist of light- or dark-
yellow, brownish points, dry scaling and
horny, or scaling and greasy, aggregated
masses of an irregular circular or oval
outline. The surface of these masses is
insensitive, and may project about an
eighth of an inch above the surface.
These masses may be readily picked off,
leaving a small, superficial, smooth, ex-
coriated surface or one covered with
minute conical elevations (enlarged se-
baceous glands). This affection rarely
appears before the fiftieth year, and may
not claim attention until fifteen or
twenty years later.
Prognosis. — The prognosis is favorable
if the proper treatment is promptly ap-
plied. When left alone the pigmented
masses are prone to epitheliomatous de-
generation, and may become foci for
carcinoma of the face, in which case the
dry scales are displaced by a scab, the
tissues become hard, and growth is more
rapid.
Treatment. — In the early stage, in-
unctions with petrolatum or olive oil
and the subsequent use of soap and warm
water will remove the trouble. When the
masses are firmer, ointments should be
applied at night, and soft soap or sapo
viridis in the morning, removing the
soap by carefully washing with clean,
warm water; applications of diachylon
ointment will heal any excoriations that
may have been produced. When marked
projection of the mass is present, the
thorough use of the curette, or nitric
acid on a pointed stick, well worked into
the parts, will remove the affected tis-
sues. If epitheliomatous change is sus-
pected, prompt excision is indicated.
CLAVUS (CORN).— Clavus is an hy-
perplasia of the corneous or horny layer
of the epidermis, in which there is an in-
growth as well as an outgrowth of horny
substance, forming circumscribed epi-
dermal thickenings, chiefly about the toes.
Corns may be hard or soft, the latter be-
ing situated between the toes, where they
become softened by maceration. Both
forms are caused by intermittent pressure
and friction. Pressure produces pain by
driving the conical mass of hardened epi-
thelium down upon the sensitive coriuni;
constant irritation may produce inflam-
mation and suppuration.
Treatment.— The use of well-fitting,
comfortable shoes made on properly
shaped lasts is the first indication. Tem-
porary relief from hard corns may be
obtained by the use of felt rings which
are applied over the corns, allowing the
latter to project through the opening.
Prolonged soaking in a warm solution of
sodium carbonate will soften the corn,
when it may be removed by gentle scrap-
ing with a sharp knife; the tender sur-
face left may be protected by covering it
with a plaster-of salicylic acid or of sali-
cylic acid with cannabis indica. Another
method is that of hardening the surface
of the corn by applications of the tinc-
ture of iodine or silver nitrate at night,
removing the hardened tissue on the fol-
lowing morning. A third method is the
use of the salicylic-collodion mixture:
Salicylic acid, 30 grains (2 Gni.); tincture
of iodine, 10 minims (0.6 c.c); extract of
cannabis indica, 10 grains (0.6 Gm.); col-
lodion, 4 drams (15 c.c); this to be
painted on the corn night and morning
for several days and then removed with
the corn, by soaking in hot water. Soft
corns are best treated by gentle scraping
to remove the softened epithelium, the
surface being then protected by a pad of
natural wool (as it is clipped from the
sheep), or of absorbent cotton, having
previously dusted the surface with a
powder composed of equal parts of zinc
oxide and boric acid. When corns be-
come inflamed, rest and warm, moist,
antiseptic dressings meet the indications.
If pus has formed it must be afforded
an exit and the wound treated with anti-
septics, iodoform, anatol or europhen.
168
SKIN, SURGICAL DISEASES OF.
Corns should never be cut too closely, as
erysipelas and gangrene may follow, espe-
cially in the aged.
VERRUCA.— Verrucse (condylomata;
warts) are circumscribed papillary ex-
crescences on the skin, variable in color,
smooth at the summit, or studded with
moniliform elevations or with clusters
of minute, pointed, horny filaments.
They may be single or multiple, hard or
soft, rounded, flattened or acuminate.
They may rapidly attain their full size,
may last indefinitely (/'. pcrstans), or
spontaneously disappear, at any stage,
and are not contagious. If picked or
wounded, warts bleed freely, being often
very vascular. The etiology of warts is
obscure.
Treatment. — The milder applications
consist of the juice of the milk-weed (As-
clcpias coniuti sen Syriaca), the tincture
of iodine, the solution of iron perchloride,
moistened powder of ammonium chloride;
stronger applications are sublimate col-
lodion (30 grains to the fluidram), glacial
acetic acid (best of acids, as it leaves no
scar), chromic acid and fuming nitric
(nitroso-nitric) acid. Excision (warts on
the face should never be cauterized, but
excised) or curettage if the warts be
soft, is the quickest method of removal;
the hypodermic injection of cocaine will
lessen or prevent the pain, and the ap-
plication of fuming nitric acid to the
stump or base will restrain the hemor-
rhage and prevent return. A 10 per cent.
salicylic acid or resorcin ointment is slow
but effectual. Electrolysis is efficient but
painful, for large warts. Ethyl chloride
spray, liquid air, and carbon dioxide
snow are efiicient. Quicklime rubbed on
the hands and washed off in an hour is
effective when warts are numerous; this
should be done twice daily and con-
tinued for a fortnight. Intravenous in-
jections of salvarsan and neosalvarsan
have been used successfully when warts
were numerous.
The internal use of >< pint (250 c.c.) of
lime-water daily for a week (Kennard) and
1 dram (4 Gm.) doses of Epsom salt
thrice daily (Ridley) have given satisfac-
tory results.
Instead of cutting or the use of caustics,
Purdon uses an India-rubber finger-stall.
if the warts are on the fingers, or an
India-rubber bandage, if they are on the
hands. The ruljl)er exerts gentle pres-
sure, while the wart is kept moist and
macerated from retained perspiration.
Venereal warts may be washed well
with bichloride or other antiseptic solu-
tion, and then dusted with iodoform,
calomel, aristol, or europhen.
HYPERTROPHIED SCARS.— When a
wound is completely healed, a cicatrix or
scar occupies its place. Normally, two
things are observed in a scar: its contrac-
tion and the gradual perfecting of its
tissues. The principal changes by' which
the latter is accomplished are the re-
moval of all the rudimental textures; the
formatiori of elastic tissue; the improve-
ment of fibrous or fibrocellular tissue of
the new cuticle till they are almost, but
not exactly, like those of natural forma-
tion; and the gradual loosening of the
scar, so that it may move easily upon
the subjacent tissues.
Treatment. — Hypertrnphied scars may
be treated by multiple incisions and
thiosinamine. Tubb}- uses a fine and
strong-backed tenotomy knife and makes
a large number of incisions in the scar
tissue, transversely to the long axis of
the scar, not more than Yio inch apart,
and extending both into the subcutaneous
fat and for about l^ inch into the adja-
cent healthy skin. Hemorrhage is stopped
by pressure alone, and then a solution
of thiosinamine is thoroughly rubbed in.
P^'rom 15 to 20 minims (1 to 1.3 c.c.) of
the solution may be injected at one time
in an adult. After injection the part is
splinted in extreme extension.
Fibrolysin plaster applied to the scar
and left for fourteen days, gave excellent
results.
Excision of the scar and repair by
plastic operation is applicable in some
cases. See also page 176.
KELOID.— Keloid (cheloid; kelis; Ali-
bert's keloid; spurious keloid) is a new
growth of connective-tissue formation
having its seat or origin in scar tissue
and resulting in the formation of single
or multiple tumors.
Symptoms. — It first appears as a pale-
red nodule which slowly increases in size,
assuming a more or less oval form, with
SKIN, SURGICAL DISEASES OF.
169
irregular, well-defined, radiating projec-
tions. From its resemblance to a crab
it derives its name. It may more rarely
assume a linear form. The new growth
is smooth, firm, elastic, pinkish, elevated,
generally devoid of hair, usually painless,
but sometimes tender when touched or
subjected to pressure; and is occasionally
the seat of the most intolerable itching,
which no external application seems to
relieve. The favorite location of this
growth is over the sternum, but it may
be situated on the mammae, the neck,
arms, and ears. In rare instances the
growth may become inflamed and assume
for a while the appearance of malignancy,
which appearance disappears usually with
the spontaneous decline of the inflam-
matory action. The development of the
growth may be slow or rapid, until a
stationary period is reached, which varies
in duration. Spontaneous disappearance
of the growth not infrequently occurs. In
some cases the growth becomes painful,
in others a pigmentary deposit is noticed.
This condition was first described by
Alibert, and is known as spurious keloid
to distinguish it from true keloid, which
does not attack scars (Erichsen).
Diagnosis. — AUbert's keloid is dilifer-
entiated from a simple cicatrix by its
diiiference in consistence, outline, color,
and elevation, and by its increase in size.
Its points of difference from hyper-
trophicd scars have been mentioned.
Etiology and Pathology. — These new
growths have their origin at the seat of
some injury (sometimes very slight) to
the skin, as the cicatrices of burns, flog-
gings, cuts, or in the lobes of the ears
when they have been pierced for the
accommodation of earrings. They are
most frequent in middle life and in the
colored race. The growth consists of
dense fibrous tissue, which involves the
corium and extends in the direction of
the connective tissue about the blood-
vessels.
Prognosis. — The prognosis is not gen-
erally very favorable, although the growths
may sometimes disappear spontaneously.
The stationary period may extend over
years or during life. Occasionally, after
a stationary period of variable duration,
an increase in size takes place.
Treatment. — The treatment of these
new growths is not very satisfactory.
The application of anodyne liniments or
hypodermic injections of morphine will
generally relieve pain when present. The
administration of large doses of liquor
potassae will often relieve the pruritus.
Removal by knife or caustics should not
be attempted while the growth is increas-
ing. Fused caustic potash is recom-
mended as best, if any caustic is used.
Multiple electrolytic puncture and re-
peated scarification, making numerous
parallel linear cuts crossed at various
angles by other parallel linear cuts, have
been suggested with the idea of replacing
the diseased scar by a healthy one.
Sodium salicylate taken internally (20
to 30 grains— 1.3 to 2 Gm. — three or four
times daily) has a marked effect in the
resolution and absorption of keloid. In-
jections of fibrolysin (35 minims — 2.3 c.c.)
made daily or even once a week has
caused the disappearance of keloid.
Radium has proven highly effectual both
for keloids, excessive scarring, and deep
fibrous adhesions. All cases of keloid re-
ported on by F. C. Harrison (1918)
showed disappearance or marked improve-
ment under radium. Weil exposed keloid
to very hard X-rays. Lesieur reported
satisfactory results in 100 cases from in-
jections of creosote in sterile olive oil,
1:15; 2 drops to 80 minims (5 c.c.) are
injected under the keloid at each sitting.
MALIGNANT DEGENERATION OF
SCARS. — The cicatrix of a burn or other
extensive scar may undergo malignant
degeneration many years after its forma-
tion. Erichsen removed a large cancroid
growth from a cicatrix of a burn, on the
forearm of a woman, seventy years after
the receipt of the injury, which happened
in childhood.
BURNS.
DEFINITION.— A burn is a high
grade of acute inflammation, following
the direct or indirect application of dry
or moist heat to a portion of the cu-
taneous or mucous surfaces.
VARIETIES.— For ease of comprehen-
sion burns have been separated into
grades according to their severity.
A temperature, slightly increased above
the normal (as, for instance, 100° F. —
170
SKIN, SURGICAL DISEASES OF.
37.8° C), produces only a slight hyper-
emia (first degree: dermatitis ambus-
tionis erythematosa), which may dis-
appear shortly after breaking the contact,
while a rise of 150° F. (65.6° C.) will
cause some appearance of vesicles and
bull?e (second degree: dermatitis am-
bustionis vesiculosa et bullosa) and de-
struction of the epidermis, the effect of
which is not relieved for days after the
removal of the burning substance, and
yet, on the other hand, heat at the boil-
ing point of water (212° F.— 100° C.)
may cause a complete carbonization of
the part, resulting in the formation of
eschars varying in color from a yellow
up to a dark brown or black or, in other
words, the production of gangrene (third
degree: dermatitis ambustionis escharot-
ica seu gangrenosa).
SYMPTOMS.— The effects of a burn
upon the body structure are both local
and constitutional. The former often
results in great disfiguration or destruc-
tion of tissue, while the latter depresses
the vital forces or terminates in death.
Local Effects. — In burns of the first
degree the appearances produced are su-
perficial. There will be observed a dis-
tinct hyperemia with redness of varying
intensity from the slightest blush up to a
pinkish red or brownish red. This may
or may not be entirely effaced by pres-
sure. This type of burn is produced by
indirect contact with the flame of a
lighted match, proximity to a heated
metal, escaping steam, and the actinic
rays of the sun. With or without treat-
ment the effect of burning to this extent
maj' disappear shorlj' after removing the
exciting cause.
In burns of the second degree the in-
flammation, while yet superficial, may
still occupy the entire epidermis. In
some cases the upper layers alone of the
cuticle may be destroyed, while vesicles
or bullae may be observed over the af-
fected surface. In still other cases the
corium is stripped entirely of its epi-
dermal covering or particles of the mem-
brane may be rolled into whitish masses
over its exposed surface. These vesicles
or bullae may be produced directly by the
contact of the heated article or indirectly
by the consequent inflammation. They
may retain their contents or, owing to
the increased flow of serum, their walls,
becoming thin and losing their elasticity,
rupture, thus allowing the escape of a
continual discharge over the denuded sur-
face. The true skin, which is exposed
either entirely or at points, shows a
highly reddened surface, over which this
continual exudation may be observed.
In this type of condition actual contact
with the heated substance takes place
either in shorter or longer durations.
Such articles as heated iron, transient or
lengthened action of flames, aiid boiling
liquids may be the exciting agent. The
effects of this form of burn do not al-
ways show to what extent they have
progressed immediately upon the removal
of the cause, because of the systemic con-
ditions which may be induced. Pain is
always present to a minor or major
degree.
Resolution takes place through coagu-
lation of the serous discharge, which
occupies the involved area as a fibro-
albuminous covering beneath which the
new skin is allowed to form.
In the burns of the third degree the
inflammation or destruction may be su-
perficial, extending over considerable area,
or deep, affecting the subcutaneoos tis-
sues, muscles, and even bones.
Resolution takes place in the uncovered
variet}' in the same manner as described
under the foregoing degree, while in the
covered variety granulations spring up
beneath the charred remains which, after
a time, desiccate and fall off, exposing a
similar surface to that of the second
degree.
In the deeper form of burn the extent
of surface involved may be small or
large, but may dip down to varying
depths. The amount of charring will usu-
ally be very great and will lie about in
masses over the burned surface, thus
preventing a view of the destruction be-
neath. Resolution even in the milder
cases is slow, and before such happens
surgical interference may be demanded.
The cause which brings about this form
of burning is usually dry heat (flames or
contact with electric wires); it entails
much greater destruction than will moist
heat. The effect upon the system is
SKIN, SURGICAL DISEASES OF.
171
alarming, and shock may carry off the
person before relief can even be attempted.
Electric and X-ray Burns. — Burns from
electricity may be observed in all the
varieties mentioned above. They may
follow^ direct or indirect contact. Exam-
ples of direct contact are observed after
handling live (charged) wires, and may
be found to destroy all parts with which
it comes into touch, or life even may be
the forfeit. Such burns resemble moist
gangrene or severe frost-bite. The pain
is often very severe and the healing pro-
cess is much slower than in the case of
ordinary burns.
A most recent form of burning of the
skin from the indirect contact of elec-
tricity is by the X-ray apparatus. Close
proximity to the ray by either covered or
uncovered parts result either in a super-
ficial or deep inflammation of the skin. It
may be observed a few hours after ex-
posure to the rays or may be delayed for
several weeks. This form of burning at-
tacks the skin alone in some instances,
while in others the deeper structures, as
the muscles, tendons, nerves, and bones
(periostitis and ostitis resulting) are in-
volved. The effects may remain for days,
weeks, or even months after the applica-
tion. The X-ray burns are supposed by
some to be produced by the action of the
ray or by particles of aluminium or
platinum reaching and being deposited in
the tissues by others, and by others to be
the result of an interference with the
nutrition of the part by the induced
static charges.
The patient may be absolutely pro-
tected from the harmful effects of this
static charge by the interposition between
the tube and the patient of a grounded
sheet of conducting material that is
readily penetrable by the X-ray, a thin
sheet of aluminium or gold-leaf spread
upon cardboard making an effectual protec-
tive shield.
Burns of Mucous Surfaces. — The mu-
cous surfaces may be affected by the
inhalation of flames, vapors (volatile or
boiling acids), boiling liquids (water,
slacked lime), and by certain substances
acting directly, such as ammonia and
sulphuric and hydrochloric acids. The
mouth, pharynx, larynx, bronchi, and
the esophagus, as well as the stomach,
share in the attack. The eye often, from
its exposed position, is the seat of burn.
Conjunctivitis often results from irritants
coming into direct contact with the eye,
and if the exciting agent is not soon re-
moved great destruction of substance or
sight may be the result.
Constitutional Effects.— The effects of
burns of the first degree upon the system
are generally slight and are limited to
pain which disappears shortly after the
removal of the exciting agent, but often
may last for several hours.
In burns of the second degree the pain
accompanies the phenomena not alone for
hours and days, but often for weeks and
even months. The shock may be of a
transient character or of an alarming in-
tensity. It may be encountered at the
time of accident or be delayed for peri-
ods varying from hours to days there-
after. When small areas are involved,
the depression may soon be relieved, but
when one-fourth or one-third of the
body is attacked death may intervene.
Burns of the third degree may be so
severe that death intervenes before pain
has time to appear. Shock at this stage
is therefore observed early and of the
worst character. Early mortality is gen-
erally due to the shock, while late mor-
tality usually occurs during the stage of
suppuration. Vomiting is often observed
in both the second and third degrees.
Children suffer more from burns than
do adults, and women more severely than
men. The temperature is not affected by
burns of the first degree, but is a marked
symptom in those of the second and third.
At the time of the accident it may de-
cline from 1 to 3 degrees below the
normal— to 97° F. (36.1° C.) or even 95°
F. (34.9° C.) and remain at that point
until reaction begins, which is in about
thirty-six or forty-eight hours, when it
rises during the next twelve to eighteen
hours to 104° F. (40° C.) or 106° F.
(41.1° C.) or more, at which point it re-
mains for a period of eight to ten days
(possibly rising and lowering at irregular
intervals), when granulations, now in fair
formation, act as a retarding agent.
Vannini reported cases of six burns of
varying degrees of severity, in all of
172
SKIN, SURGICAL DISEASES OF.
which glycosuria was present. The gly-
cosuria was, as a rule, transitory, and
was, in all probability, toxic in its origin,
and connected with hyperglycemia. When
sugar is present after burns, the diet of
the patient should be modified.
COMPLICATIONS.— The after-effects
of burns may be concentrated upon the
viscera (neural, thoracic, and ventral cavi-
ties) or directly upon the part affected
(cicatrices, contractions, and fractures of
bone). Burns of the first degree remain
uncomplicated, while those of the second
and third present many variations. The
meninges (arachnitis following burns of
the head), as well as the brain proper,
may become congested or even highly
inflamed, the sufferer presenting all the
symptoms of restlessness and delirium
ending either in convulsions or coma.
Tetanus is an early complication ob-
served. Bronchitis and pneumonia often
result either from inhalations or indi-
rectly from surface burns. Congestion in
the kidney has been noted, with resulting
albuminuria or hemoglobinuria, while in
many cases the urine becomes exceedingly
scanty. Autopsies have shown rupture of
the diaphragm and stomach, accompanied
by contraction of the bladder. Amyloid
degeneration in the viscera has been noted
after prolonged suppuration. Inflamma-
tion of the gastrointestinal tract with
the formation of an ulcer (usually one,
but more rarely several) of the duodenum
(at its pyloric end) frequently occurs.
This ulceration may begin early (four or
five days) or it may be delayed for
weeks, although without the appearance
of rectal hemorrhage or perforation, with
consequent peritonitis, we have no means
of determining its presence. At times
this inflammation extends to the colon
and causes diarrhea. Burns affecting
either the chest or abdomen are the in-
ducing cause, although severe burns at
other points may produce them. Sep-
ticemia, pj^emia, or erysipelas (the strep-
tococci being found after death in the
blood) may be the fatal ending.
The theories of the causes of death from
burns may be divided into four classes:
(1) death from shock or extreme pain;
(2) embolism, thrombosis, and destruc-
tion of the blood-elements; (3) pyemic
infection through the burned surface;
(4) poisons formed by the action of heat
on the tissues, or autointoxication from
deficient excretion by the skin. By ex-
perimenting upon dogs and rabbits it is
personally claimed that the intoxication
theory is the correct one.
The attempt of nature to restore a cov-
ering for these denuded tissues often re-
sults unwisely. Vicious scars, adhesions
of contiguous parts (causing webbed fin-
gers, the arm being attached to the side
by granulations), and deformities may be
encountered. Calcareous degeneration or
even epithelioma may attack the scars.
Pressure upon the terminals of the nerves
may either cause neuralgia or spasm of
the glottis, which may demand surgical
interference for its removal. Finally,
keloidal tumors may be observed as a
consequence of vicious scarring. All of
the scar may not be affected with keloid,
as, for instance, one end may show the
prolongations, while the other resembles
ordinary cicatrices. The contractions of
the skin after scarring may produce great
deformit}^ and the hand may be drawn
backward upon the arm or talipes cal-
caneus may result or other disfigurations
too numerous to mention may be shown.
Exposure of joints has taken place by
ankylosis. Bones have been fractured
from loss of substance (cooking of the
muscles).
DIAGNOSIS.— Ordinarily the recog-
nition of burns is not a dithcult task, al-
though the differentiation of the varieties,
especially of the second and third degrees,
may demand careful examination. Burn-
ing flesh with destruction of its particles^,
exposure of the underlying tissues (mus-
cles, bones, etc.), will be a train of symp-
toms not to be controverted. The dif-
ference between burns and scalds often
may occasion difficulty, but the fact of
the greater and deeper destruction of the
former with the more superficial charac-
ter af the latter will generally be suf-
ficient. The loss of hair follows the for-
mer because of this deep destruction of
the hair-follicle and papilla.
MEDICOLEGAL ASPECTS OF
BURNS. — In cases where the persons
have been alive when they were exposed
to the fire, soot is found in the ramifica-
SKIN, SURGICAL DISEASES OF
173
tions of the trachea and bronchi. If the
red blood-corpuscles are found disinte-
grated and disfigured throughout, then
this is a further sign of a person having
been burnt while alive.
The presence of carbon monoxide in
the blood is an almost positive proof that
the person during life was not exposed to
the influence of fire.
PROGNOSIS.— The termination of this
class of injuries is often of serious import,
especially when medicolegal questions
arise. This should be determined by the
several factors which arise in each case.
Consideration must be given to indi-
viduality of the sufferer, both his age and
constitutional acquirements; the extent of
the burn, both as to surface and depth in-
volved; the location of the injury, and the
nature of the exciting medium. The ef-
fects upon strong, robust subjects are
not so marked as upon those of weaker
constitutions, and while the same degree
or extent of burn will soon be recovered
from by the former, the most dire results
may follow in the latter persons. Thus it
may be noticed that burns among ma-
chinists, glass-blowers, plumbers, and
foundrymen will not be so serious as
would the same degree or extent among
clerks or those engaged in gentlemanly
pursuits. Colored persons suffer less se-
verely than do the white. Females, on
account of more delicate systems, are less
able to resist shock than are the males.
Middle life is not so severely affected as
are children or aged people. Some per-
sons may be able to resist the shock only
to be carried off by the complications that
arise.
Surface involvement seems to exert a
greater depression or fatality than does
depth of tissue. A burn, even of the first
degree, which occupies an extended area
and those of the second may terminate
fatally if one-fourth or one-third of the
superficial parts are involved; a fatal is-
sue may also occur in burns occupying
one-half of the body surface. A burn of
the second degree which occupies only a
limited extent of surface, but which de-
stroys the epidermis entire, may end in
recovery, while those of the third may,
through their deep involvement, produce
complications with which we are unable
to combat. Burns occupying the abdo-
men give the highest mortality, while
those of the thorax are only second to a
slightly minor extent; but those of the
head, neck, and limbs prove fatal in
many instances. Of twenty-six cases seen
by Sajous after a boiler explosion on the
Lake of Geneva, in 1892, twenty-two died
within a few hours after the accident, al-
though, with few exceptions, the scalds,
though involving the greater part of the
body, did not reach beyond the epidermic
layer, excepting over the face and hands.
The length of time required for the
partial or complete reparation of the sur-
face may be an important question in
inedicolegal cases. This can only be gov-
erned by the type of injury, the length of
contact of the exciting agent, the nature
of the affected person, and the general
aspects of the case in question.
TREATMENT. — Constitutional. — The
constitutional treatment is to be directed
toward the relief of pain, the restoration
of the depressed vitality at the time
of accident, — i.e., sustaining the system
throughout the entire restorative process.
Pain is best relieved by opium, or its al-
kaloid, morphine (preferably by hypoder-
mic injection), because these agents have
little, if any, depressing action upon the
cardiac functions. The dose required will
be much greater than ordinarily used, be-
cause of the sudden character and great
amount of depression in these injuries.
Vitality must be restored as quickly as
possible, and the use of ammonia (prefer-
ably carbonate), strychnine, and caffeine
(because of their stimulating effect upon
the cardiac muscle) ; hot drinks, such as
milk and tea; alcohol in the form of
whisky or brandy, and the production of
local or generalized sweating. A most
desirable plan of restoring heat is by
using hot-water bottles placed at regular
points so as to diffuse its effects. Other
means, as, for instance, covering the body
with a sheet and conveying heat through
a pipe or by placing heated bricks beneath
this covering. To keep the sufferer fairly
comfortable during the local treatment
stimulation must be kept up, care being
taken not to produce overactivity and thus
allow reaction to prove as deleterious as
the effect of the burn.
174
SKIN, SURGICAL DISEASES OF.
Tlic functions of the body must be
regulated, the bowels being kept free or
confined, according to the conditions pres-
ent: the action of the kidneys should be
watched. In some cases it may be wise
to anesthetize the patient during the first
few hours immediately following the burn,
and especiall}^ during the first dressings
of aggravated cases.
Local. — The local treatment is to be
directed toward the limitation of the re-
sulting inflammation, the prevention of
septic infection, assisting the normal
elimination of the eschar, the develop-
ment of granulations, and limitation of
the deformity.
In burns of the first degree little or
no treatment may be demanded. In the
more aggravated cases of this t3'pe the
application of home measures, such as
sodium bicarbonate, the white of egg and
sweet oil (equal parts), lead-water and
laudanum, and the various hot or cold
means generally at the disposal of
housewives.
Burns of the second and third degrees
must be more strenuously treated. It is
often a difficult problem to know which
is the more soothing application to be
advised and from which we may get the
better result. In one case hot applica-
tions, in another cold; in some wet, and in
others dry measures are to be given.
The vesicles, if numerous, should be un-
touched; but if onl}'^ a few, they are best
evacuated.
Prof. S. D. Gross was wont, in many
mild and severe cases, to use ordinarj-
white-lead paint; this is a remarkably ef-
ficacious measure. Mere painting of the
burn, as if it were an article of furniture,
etc., causes immediate cessation of the pain.
The use of carbolized petrolatum (3 to
6 per cent.), watery solutions of carbolic
acid (4 per cent.), bismuth subnitrate
(Vi to 1 dram — 2 to 4 Gm. — to 1 ounce —
30 Gm. — of ointment of zinc oxide or
petrolatum), boric acid (either in watery
saturated solutions or ointments of either
zinc oxide or petrolatum in strengths
varA'ing from 6 to 25 per cent.), sodium
bicarbonate in almost full strength (in
ointment or watery solutions), and starch
in varying proportions will usually" be
found very efficacious.
Turpentine, where granulations are slug-
gish, will give excellent results used
cither in full or diluted strength, giving
care not to produce too much stimulation.
When there are large vesicles, these are
opened on the second or third day. It is
best to keep the turpentine off the healthy
skin if possible to avoid local irritation.
Surgery of this day has placed many
excellent antiseptics at our disposal, and
there is no better application than mer-
cury bichloride in the proportion of 1 to
lOUO parts of water and kept in constant
contact, the dressings being made without
removing the former cloths.
Ichthyol in watery solutions (1 to 8,
or stronger, or in glycerin, similar
strength), or even in from 12 to 36 per
cent, ointment with zinc oxide or petrola-
tum and the iodine derivatives, such as
iodol, aristol, europhen (given preferably
in ointment 3 to 6 per cent, with petrola-
tum or lard) are reliable measures.
Thiol has been found useful for all de-
grees of burn; it allaj-s pain verj- rapidly
and arrests cutaneous hyperemia, in this
manner tending to prevent ulceration and
scarring.
Aristol is another valuable agent in
burns of the second and third degrees,
and has been found strikingly effective
where other remedies have failed.
It may be used in the form of powder
or mixed with oil or petrolatum. The
application of aristol powder directly to
the wound at the beginning hinders the
dressing from soaking up the secretion;
when the latter has diminished, however,
aristol may be applied either alone or in
a 10 per cent, ointment with olive oil,
petrolatum, and lanolin.
Many authoritative surgeons have lauded
picric acid used in saturated solutions
with water (increasing the solubility by
means of the addition of 1 ounce — 30
c.c. — of alcohol, as the acid is soluble to
the extent of only 2 drams — 8 Gm. — to
the quart — liter — of water). It is par-
ticularly useful for the relief of pain
and it greatly assists the formation of
granulations. .
The combination of picric and citric
acids, which Esliach devised for the de-
tection of albumin, is more effective than
the picric acid alone, in burns of the sec-
SKIN, SURGICAL DISEASES OF. 175
ond degree. Esbach's solution consists of Granulations may often be assisted by
10 parts of picric acid, 20 of citric acid, powders of acetanilide in full strength, or
and KKX) of water. The bullae and vesi- with equal parts of boric acid, dusted over
cles should, be opened with a clean blade the area, or by means of iodol, europhen
and the fluid applied freely. Repeated ap- or aristol (3 to 12 per cent.) with powdered
plication of tincture of ferric chloride is starch or in ointment. Scarlet red in 10
another useful form of treatment. Cal- per cent, solution may also be used.
cined magnesia, in a paste made with Limitation of deformity is often a seri-
water, is serviceable in l)urns of the first ous problem though in some measure ob-
and second degrees. Iodoform, as an viated by paraffin treatment. Splints may
analgesic and antiseptic, may be left in be utilized and they should be kept applied
situ for some time. Potassium nitrate for some time after the parts have healed
solution is useful, chiefly as refrigerant. because of the inherent tendency to the
The paraffin treatment of severe burns contraction for long periods, even years,
constitutes a distinct advance over the pro- after an apparent cure. Bandages are to
cedures previously in general use. Be- be kept continuously applied to prevent
sides forming a painless dressing, which contiguous surfaces from becoming ag-
is easy of application and removal, and glutinated. Massage must be advised at
does not favor infection, it results in more the very earliest moment so as to restore
rapid healing, and leaves a smooth, soft, the pliability of the part and prevent anky-
pliable scar, with little or no tendency to losis when a joint is involved. Even with
contracture and deformity. Either am- all the measures that we can adopt the
brine or one of the numerous substitutes loss of skin-tissue may be so extensive
for it may be used. The burn is first that skin-grafting will be the only means
washed with sterile water, saline solution, with which we can hope to restore the
or boric acid solution; it may be sprayed integrity of the part. The relief of cica-
with a 3 to 5 per cent, solution of dichlo- trices or contractions, ankylosis, or pres-
ramine-T, followed, if necessary, by liquid sure upon the nerve-filaments sometimes
petrolatum to allay pain. It is then dried requires the most energetic surgical in-
with sterile gauze or an electric dryer, and terference.
the paraffin preparation applied with a TREATMENT OF ELECTRICAL
broad camel's hair brush or special sprav BURNS. — Elder advises that the part sub-
apparatus. Shere recommends the follow- jected to the burn be immersed and kept in
ing mixture: ^ warm carbolic-lotion bath, 1 per cent.,
,,„ . ,. ic ^,,„,^^ taking precautions against the possibility
White vaseline 15 ounces. , ,,"' ^ % i u
,...,,, ^ 9 ^,,„ooc of the occurrence of secondary hemor-
Liquid petrolatum Z ounces. -'
Oil of euealyptus 1 ounce. --hage. If secondary hemorrhage occur or
Paraffin (melt. pt. 42.7° C.) .. 16 ounces. ^hen a definite Ime^ of demarcation has
formed, the necrosed tissue must be re-
Iv lute uax. J T , ,. .
„. , J. , , T/ ^,,„„„ moved. In many cases amputation is
Pix burgundica, of each ^ ounce. ,.., ,-r, i,, .u
necessary, but the skin-Haps should not be
For the first few days, 1 dram each ot closed, because large masses of muscle are
thymol, iodide and menthol are added to gm-e to slough away subsequently. The
allay infection and pain; later, >2 to 1 per wound should be allowed to granulate,
cent, of scarlet red, and when epithclializa- and subsequently be skin-grafted. Imme-
tion is nearly complete, bismuth subgal- diately after the burn hypodermic injec-
late, 1 to 10. A thin layer of cotton is tions of morphine (% grain — 0.01 Gm.)
placed over the first layer of paraffin, a and strychnine (V.s(» grain — 0.002 Gm.) may
second paraffin coating applied, and the j^g given alternately. To lessen the oft'en-
dressing completed with cotton and band- give odor the 1 per cent, carbolic lotion
age. Redressing is done daily at first, niay be replaced by a bath of 1 in 10,000
later on alternate days. mercury bichloride. In addition, mor-
The lethal tendency of burns is best phine, phenacetin, caffeine, chloral hydrate,
met by removing the necrosed tissues and and potassium bromide may be adminis-
infusion of saline solution, repeated daily. tered together.
176
SODIUM (SAJOUS).
Immobilization of the part aiul protec-
tion with sterile gauze arc necessary,
and, if the hum is extensive, skin-grafting.
SCAR-TISSUE DEFORMITIES.—
Scars, even when adherent to hones, j)ain-
ful thickenings following injuries or hums,
or of the tendons, are favorably influenced
by X-rays. Grace (Am. Jour, of Pllectr.
and Radiol., Oct., 1919) uses a filter of
1 mm. of aluminium for the superficial
cases and of 2 mm. for the deeper. The
Palzsche method, a salve composed of
pepsin, hydrochloric acid, and phenic acid,
each 1 per cent., rubbed into the scar twice
daily, is also effective according to Schues-
sler (Miiench. med. Woch., Ixviii, 72, 1921).
Moist compresses are applied at night.
C, W. and S.
SODIUM* — Sodium, or natrium, is
a light, soft, ductile, malleable metal,
of silver-white luster when freshly cut,
and of dull-gray color when oxidized
by air. Like potassium, it has a strong
afifinity for oxygen, and must be kept
immersed in a liquid free from oxy-
gen, such as benzene or naphtha.
Thrown upon water, it burns with a
bright yellow flame, imiting with the
oxygen of some of the water and
forming in the remainder a solution of
sodium hydroxide. The pure metal is
not used in medicine, but yields a
larger number of official compounds
than any other element.
Upon a therapeutic basis, the fol-
lowing classification of some of the
sodium compounds may be made : —
Caustics: Soda, and soda with lime
(unofficial).
Purgatives: Sodium phosphate, sodium
sulphate, and potassium and sodium tar-
trate.
Systemic antacids: Sodium acetate, so-
dium bicarbonate, monohydrated sodium
carbonate, sodium citrate, and potassium
and sodium tartrate.
Diuretics: Sodium acetate, sodium ben-
zoate, sodium bicarbonate, monohydrated
sodium carbonate, sodium citrate, and
potassium and sodium tartrate.
Febrifuges: Sodium acetate, sodium
benzoate, sodium citrate, and sodium
salicylate.
Antiseptics: Sodium benzoate, sodium
borate, sodium chlorate, sodium hypo-
chlorite, sodium phenolsulphonate, and
sodium salicylate.
PREPARATIONS AND DOSES.
— The official preparations of sodium
are: —
Sod a hydroxidnm, U. S. P. (sodium
hydroxide or hydrate: caustic soda),
rapidly deliquescent, and acquiring a
coating of sodium carbonate; soluble
in 1 part of water and freely in alcohol.
Liquor sodii hydroxidi, U. S. P.
(solution of sodium hydroxide), of
about 5 per cent, strength. Dose, 10
to 30 minims (0.6 to 2 c.c).
Liquor soda chlorinata, U. S. P.
(solution of chlorinated soda; Labar-
raque's solution), an aqueous solution
of several chlorine compounds of so-
dium, containing at least 2.4 per cent.
by weight of available chlorine. Dose,
10 to 30 minims (0.6 to 2 c.c).
Sodii acetas, U. S. P. (sodium
acetate), soluble in 1 part of water
and in 23 parts of alcohol. Dose, 10
to 30 grains (0.6 to 2 Gm.).
Sodii arsenas, U. S. P. (sodium ar-
senate). Dose, Yxo grain (0.006 Gm.).
(See Arsenic.)
Sodii arsenas exsiccatus, U. S. P.
(dried sodium arsenate). Dose, %o
grain (0.003 Gm.). (See Arsenic.)
Liquor sodii arscnatis, U. S. P.
(solution of sodium arsenate). Dose,
3 minims (0.2 c.c). (See Arsenic.)
Sodii henzoas, U. S. P. (sodium
benzoate), soluble in 1.6 parts of
water and in 43 parts of alcohol. Dose,
10 to 20 grains (0.6 to 1.3 Gm.). (See
i^ENzoic Acid.)
Sodii bicarhonas, U. S. P. (sodium
bicarbonate, acid sodium carbonate,
baking soda), soluble in 12 parts of
SODIUM (SAJOUS).
177
water, insoluble in alcohol ; converted
into sodium carbonate on boiling its
solution. Dose, 10 to 60 grains (0.6
to 4 Gm.).
Sodium bicarbonate should only be
given in small doses (12 to IS grains
— 0.75 to 1 Gm.) several times daily.
The acidity is tlius diminished suffi-
ciently to reduce the pain, yet an
increased flow of acid is not stimu-
lated. It has been proven that 15 to
45 grains (1 to 3 Gm.) given before,
during, or after a test-meal will favor
the passage of the food from the
stomach into the intestines, while
larger doses may cause a spasm.
Even if the drug is given for a long
time in the doses mentioned, cachexia
will not set in. The fear that over-
loading of the blood with sodium
may lead to increased production of
hydrochloric acid is very remote. E.
Binet (Progres med., 3, 1911).
Trocliisci sodii bicarbonatis, U. S. P.
(troches or lozenges of sodium bicar-
bonate), each containing 3 grains (0.2
Gm.) of the bicarbonate and Vq grain
(0.01 Gm.) of nutmeg.
Mistura rhei composita, N. F. (mix-
ture of rhubarb and soda). Dose, 2
fluidrams (8 c.c). (See Rhubarb.)
Sodii bisulphis, U. S. P. VIII
(sodium bisulphite; acid sodium sul-
phite; leucogen), unpleasant in taste,
gradually oxidized to sulphate on ex-
posure to air, soluble in 3.5 parts of
water and in 70 parts of alcohol.
Dose, 7y2 grains (0.5 Gm.).
Sodii boras, U. S. P. (sodium borate;
borax), soluble in 20.4 parts of cold
water, in 0.5 part of boiling water, and
in 1 part of glycerin, with which it
reacts to form boroglyceride, with evo-
lution of gas ; insoluble in alcohol.
Dose, yj/z grains (0.5 Gm.). (See
I!oRic Acid.)
Sodii bromidum, U. vS. P. (sodium
bromide). Dose, 10 to 60 grains (0.6
to 4 Gm.). (See Bromine.)
8—12
Sodii carbonas monohydratus, U. S. P.
(monohydrated sodium carbonate),
containing only one molecule of water
of crystallization, and therefore nearly
twice as strong as the ordinary soditmi
carbonate ; soluble in 2.9 parts of water
and in 8 parts of glycerin, insoluble in
alcohol. Dose, 4 grains (0.25 Gm.).
Sodii cyanidnm, U. S. P. (sodium
cyanide), deliquescent and smelling of
hydrocyanic acid ; freely soluble.
Sodii glyccrophosplias, U. S. P.
(sodium glycerophosphate), saline in
taste ; freely soluble. Dose, 4 grains
(0.25 Gm.).
Sodii chloridum, U. S. P. (sodium
chloride; salt), at least 99 per cent,
pure, soluble in 2.8 parts of water,
almost insoluble in alcohol. Dose, as
emetic, 4 drams (16 Gm.).
Sodii citrus, U. S. P. (sodium ci-
trate), with a cooling, saline taste;
soluble in 1.1 parts of water, slightly
soluble in alcohol. Dose, 10 to 60
grains (0.6 to 4 Gm.).
Sodii hypophosphis, U. S. P. (so-
dium hypophosphite), very deliques-
cent, soluble in 1 part of water and
in 25 parts of alcohol. Dose, 5 to 30
grains (0.3 to 2 Gm.). (See Phos-
phoric Acid.)
Syrupus hypophosphitum, U. S. P.
(syrup of hypophosphites). Dose, 1
to 2 fluidrams (4 to 8 c.c). (See
Phosphoric Acid.)
Sodii indigotindisulphonas, U. S. P.
(indigo carmine), a blue powder or
purple paste ; sparingly soluble in
water, yielding a dark blue solution.
Sodii iodidum, U. S. P. (sodium
iodide). Dose, 5 to 60 (0.3 to 4 Gm.).
(See Iodine.)
Sodii nitras, U. S. P. VIII (sodium
nitrate; Ghili saltpeter; cubic niter),
with a cooling, saline, slightly bittei
taste; soluble in 1.1 parts of water and
178 SODIUM (SAJOUS).
in about 100 parts of alcohol. Dose, cent in the air; soluble in 2.8 parts
5 to 15 grains (0.3 to 1 Gm.). of water and in glycerin, insoluble in
Sod a nit r is, U. S. P. (sodium ni- alcohol. Dose, 1 to 8 drams (4 to 32
trite). Dose, 1 grain (0.06 Gm.). Gm.).
(See Nitrites.) Sodii sidpJiis exsiccatus, U. S. P.
Sodii phcnolsidphonas, U. S. P. (so- (sodium sulnhitcV with saline, sulphur-
dium phenolsulphonate or sulphocar- ous taste ; soluble in 2 parts of water,
bolate), with a cooling, saline, bitter sparingly soluble in alcohol. Dose, 15
taste; soluble in 4.8 parts of water and grains (1 Gm.).
in about 130 parts of alcohol. Dose, Sodii thiosidpJias, U. S. P. (sodium
4 grains (0.25 Gm.), thiosulphate or hyposulphite), with a
Sodii phosphas, U. S. P. (sodium cooling, afterward bitter, taste; solu-
phosphate; disodium hydrogen ortho- ble in about 0.35 part of water,
phosphate), efflorescent in the air; slightly soluble in oil of turpentine,
soluble in 5.5 parts of water, insoluble insoluble in alcohol ; the aqueous solu-
in alcohol; an aqueous solution, is tion is rapidly decomposed by boiling,
slightly alkaline to htmus. Dose, 30 Dose, 5 to 20 grains (0.3 to 1.25 Gm.).
grains to 4 drams (2 to 15 Gm,). (See Potassii et sodii tartras, U. S. P.
Phosphoric Acid.) (Rochelle salt). Dose, 1 to 8 drams
Sodii phosphas cffervescens, U, S. P. (4 to 30 Gm.). (See Potassium.)
(effervescent sodium phosphate), con- Among the sodium preparations
taining 20 per cent, of exsiccated so- recognized in the National Formulary
dium phosphate, together with sodium are the following: —
bicarbonate, tartaric acid, and citric Soda cum cake, N. F, (soda with
acid. Dose, 2 to 8 drams (8 to 30 lime; London paste), a paste consist-
Gm,), (See Phosphoric Acid.) ing of sodium hydroxide and imslaked
Sodii phosphas cxsiccatns, U. S. P. lime in equal parts, employed as escha-
(dried sodium phosphate). Dose, 15 rotic.
grains to 2 drams (1 to 8 Gm.). (See Liquor antisepticus alkalinus, N, F.
Phosphoric Acid.) (alkaline antiseptic solution, contain-
Sodii perhoras, U. S. P. (sodium ing, among other substances, sodium
perborate) ; gives off 9 per cent, of borate, sodium benzoate, and oil of
oxygen in warm or moist air; white gaultheria. (See Salicylic Acid.)
crystalline granules or powder; soluble Liquor sodii arsenatis, Pearson, N.F.
in water. Dose, grain (0.06 Gm.). (Pearson's solution). (See Arsenic.)
Liquor sodii phosphatis compositus, Liquor hypophosphitum, N. F, (solu-
U. S, P. (compound solution of sodium tion of hypophosphites). Dose, 1
phosphate), a 100 per cent, solution of fiuidram (4 c.c). To replace the offi-
sodium (citro) phosphate, containing cial syrup of hypophosphites when
also 4 per cent, of sodium nitrate, sugar is to be avoided.
Dose, ^ to 4 fluidrams.(2 to 16 c.c). Liquor hypophosphitum compositus,
Sodii salicylas, U. S. P. (sodium N. F. (compound solution of hypo-
salicylate). Dose, 15 grains. (See phosphites). Dose, 1 fluidram (4 c.c).
Salicylic Acid.) Liquor sodii boratis compositus, N.F.
Sodii sulphas, U. S. P. (sodium sul- (Dobell's solution), containing phenol,
phate; glauber salt), rapidly efflores- 0.3 per cent.; sodium borate and bi-
SODIUM (SAJOUS).
179
carbonate, of each, 1.5 per cent., and
glycerin, 3.5 per cent., in sterile water.
Liquor sodii carbolatus, N. F. Ill
(carbolated soda solution), consisting
of phenol, 50 per cent, in water, to-
gether with sodium hydroxide, 3.5 per
cent.
Liquor sodii citratis, N. F. (solution
of sodium citrate; potio Riveri), made
from citric acid, 2 per cent., and so-
dium bicarbonate, 2.5 per cent., in
water. Dose, 2 fluidrams (8 c.c).
Liquor sodii citrotartratis cffcrvcs-
ccns, N. F. (tartrocitric lemonade).
Dose, 12 flviidounces (360 c.c).
Liquor sodii oleatis, N. F. Ill (solu-
tion of soap).
Elixir sodii hromidi, N. F. (elixir of
sodium bromide). Dose, 2 fluidrams
(8 c.c), containing 20 grains (1.3 Gm.)
of the bromide.
Elixir sodii hypophosphitis, N. F.
(elixir of sodium hypophosphite).
Dose, 1 fluidram (4 c.c).
Elixir sodii salicylatis, N. F. (elixir
of sodium salicylate). Dose, 1 fluidram
(4 c.c). (See Salicylic Acid.)
Syrupus bromidorum, N. F. (syrup
of the bromides). Dose, 1 fluidram (4
c.c).
Syrupus calcii et sodii hypophos-
phitum, N. F. (syrup of calcium and
sodium hypophosphites). Dose, 1 flui-
dram (4 c.c).
Syrupus sodii hypophosphitis, N. F.
(syrup of sodium hypophosphite).
Dose, 1 fluidram (4 c.c).
Liquor soda et nienthcc, N. F. (soda
mint solution), consisting of aromatic
spirit of ammonia, 1 part ; sodium bi-
carbonate, 5 parts, in spearmint-water,
enough to make 100 .parts. Dose, 2
fluidrams (8 c.c).
Syrupus hypophosphitum composi-
tns, N. F. (compound syrup of hypo-
phosphites), containing hypophosphites,
quinine, and strychnine. Dose, 2
fluidrams (8 c.c).
Sodii borobcncoas, N. F. (sodium
borobenzoate), a mixture of sodium
borate, 3 parts, with sodium benzoate,
4 parts. Dose, 10 to 30 grains (0.6 to
2 Gm.).
Sal Carolinum factitiiim, N. F. (ar-
tificial Carlsbad salt), an amorphous
powder consisting of sodium sulphate
(dried), 18 parts; sodium bicarbonate,
36 parts; sodium chloride, 18 parts,
and potassium sulphate, 28 parts. To
be dissolved in 200 parts of water.
Dose, 6 fluidounces (200 c c), repre-
senting an equal volume of Carlsbad
water (Sprudel). If the crystalline
preparation of the same nature be used,
1.75 parts of the salt are to be dis-
solved in 200 parts of water.
Sal Kissingcnse factitium, N. F.
(artificial Kissingen salt), consistmg of
sodium chloride, 357 parts ; sodium
bicarbonate, 107 parts; magnesium sul-
phate (anhydrous), 12 parts, and
potassium chloride, 17 parts. One and
a half parts of the salt are to be dis-
solved in 200 parts of water. Dose,
6 fluidounces, representing an equal
volume of Kissingen water (Rakoczy).
Sal Vichy anum factitium, N. F. (ar-
tificial Vichy salt), composed of so-
dium bicarbonate, 846 parts ; sodium
chloride, 77 parts, and magnesium sul-
phate (anhydrous) 80 parts, and po-
tassium carbonate, 38 parts. To be
dissolved in 200 parts of water. Dose,
6 fluidounces (200 cc), representing
an equal volume of Vichy water
(Grande Grille spring).
Pulvis satis Carolini factitii effcr-
vcsccns, N. F. (efi^ervescent artificial
Carlsbad salt). Dose, 90 grains (6
Gm.) in 6 ounces (200 c.c.) of water.
Pulvis salts Kissingensis factitii ef-
fervescens, N. F. (effervescent artifi-
180
SODIUM (SAJOUS).
cial Ki.vsmj^cii .^.iii;. lAJ^^c, «S0 grains
(5.5 (jm. ) in 6 Huidounces (2(K) cc.)
of water.
f'ulri^ salis I'ichyani fiutitii effer-
vt:sctnui, NT. F. (effervescent artilicial
Vichy salt). D<:>se, 57 grains (3.75
(im.) in 6 rtuidouncea (200 c.c.) ot
water.
f'ldrif .uiJui i u.nyam j(U:tuii effer-
vcM<-its cum lithio, M. F. (effervescent
artificial Vichy .salt witJi lithium).
Dose, 'X) grains {h (Jm,), repre.senting
14 grains (I Gno,) of artificial Vichy
salt and 5 grains (0.,? Gm,) of litliium
citrate.
PHYSrOLOCrCAL ACTION. —
Sofliunx as an element or ion exerts in
nio<lerate amounts, different from po
tassium, little or no effect upon tJie
ti.ssues of higher animals. That the
.sodium ion may exert a deleteriiitJs ac-
tion on s<jme animal cell,s is shown,
htiwever, l>y tJie (^b.se.rvation tlaat .some
ova and fish ordinarily inJiahiting .sea-
water survive longer when place<l in
distillerl water than when place^l in a
solution of .«iodium chioride {."^i-itonic
with sea-water. More concentr.ntr i
.solutions of .soflirim chloride, in ai;>..
tion to a possible ionic poi>i(inous ef-
fect of tJie kind ju.st descriJied prcxluc;
the effects characteristic of "salt ac-
tion" in general, viz., witJidrawal of
water from cells, with corresponding
shrinkage ai the latter and, where the
occasion present^*, effect-9 due to irrita-
tion, such as vomiting in the case of
the stfjmach.
According to tiie e:itpcriraents of
Miinch, exhibition for a few days of
large quantities of .sorlium chloride in
man causes at first a ^0n decrea.'ie
in excretion (especially renal), with a
corresponding gain of body weiebt ;
after a time, however, the excretions
•ncrea.se and the weiglit decrcn
Small amount.>i ol .>alt have been found
at times to les.^en the acidity of the
ga.stric juice, but the greater palatabil-
ity of f<X)d .sea.soned with salt may
counteract this by augmenting the re-
rtex ga.stric .secretion. The salivary
How is increased by salt, partly tlirough
reflex action and partly because some
of it is excreted by tiie .salivary glands.
.-Xhsorption of ins:;"ested hypotonic
.soluti<ins of .salt takes place chiefiy
fn^m the intchtine, and resultsi in a
diluted Condition of the bloxl — hy<lre-
mia — which induces diuresis. The flow
of urine is increased more by direct
.saline infusion into Uie bloo<i than by
sahne solution (or water) absijrbcd
fr<im tJie st<:)mach and b<:)web Hyper-
tonic salt Si^lution injected into the
blo(xi causes marked diuresis tii rough
absorption of water from the bcwly ti.s-
sues, hxst hypertonic salt solution in-
gested causes littie or no diuresis, as
tht salt i,s only slowly absorbed from
it, and though tending, for a time, to
increase tiie total ludk of the blood,
does not render it hydremic.
Sodium kydroxidt: (caustic .sex la),
like potassium hydroxide and calcium
oxide, is a .strong caustic, de.str<jying
i4e by abstraction of water, dissolu-
tion of albumin, and .saponification of
fats. .Similar effects arc produced by
liquor sodii hydroxidi and by .scx^la cnm
calce (N. P.).
Sodium hypochionte, official \u the
liquor sod^e chlorinatjc or I^l:>arraquc's
sM^lution, gives off chlorine and pos-
.sesses the anti.septic, deodorant, and
bleaching properties of tiie latter. It
is decidedly irrit.ating to the tissues,
but this property may be reduced,
seemingly without loss of anti.septic
power, by the addition of sufficient
Ixiric acid to neutralize the free alkali
in the preparation.
SODIHIt C5.\rOL'SK
isi
I
jikaljej wtth. the veg^fcibte vtciu^. b>
nt^ipjly obijerbed ami oxiUiitKi m. tfee
sy^ton tx> 6?cni soiiimir ct"
w-fickfit tnsoreases tire al&almitry . . . .
btocti irol crtmt. iimi erases limresij.
Ov^r dinict ■'*::"-^uti <>>£ ilkalrcce ctr-
bomttes or t ' — -ittt^ suviiam: :ic«tite
xml strnilar salH fctvi* tfee idv^nctge
©f not netdn- . ice gastnjc jotoj.
te^Bt tx> mocoos nsatibntnies* exerts a:
isQotfirag: dfect.. ami ttaais- - - ' ■;
thick nmoiSv. Tt ts cooMtv- a' - ■-
the alfciTmitr of its sofation^ c: .:j.,<s
oa sranaiin^. b«^ra-^" "'""" the toss of
carbon, dio-xide^ ,^ 'n dttote sota-
tHjtt 1s?> Esotabfil contractile organs, en-
ctoJirrg- vesijel-walls ami ciTirateil eip-t-
rftefimiL Bt canses for a t
tHate altaBis^ cner^Esevi actrvctr anu.
tooKitjr, ami ai certani p- an:
BBcreased resfetance te> asfifevea :••-,"
QXTg!e3i exdnsiott: liate- -•- : • '^"- ■
activitT c? replaced by :.,.. ._-..-^>.\:.
Expertmoits ixt dogs- have ??''
rirrtr the aQdhne carbonates, a
tereti tncemaltT. (fe not trrliaen.ce the
race €>£ gastrtc secre:- ■ They temi.
tQwever, te nacerease gastric motilrtv
hf ■vrtrtne o€ the carbon '-
T^Sfl throc^ reacttott wini cae iy — ■-
cMornr acid of the gastric imce. •" "
UE^ also m themselves-^ by '-rr-.--.- -^
:d%&t local trriratEoni.. esjsrt j. ..- jI
cannmatrve ettect. rdieving- gaseJtis
lijtonioa artti the consequent pain.
E^rvre grains i Q. J Gm. ) <:JC ^odnini W.~
carbi-^nalK. if completely utilized in the
destnictaott of the gastric aciil are
c^abfe QC aetitrafizmg- ab«:irt 154
oraKes o€ gastric ' -. ■ :.
strength. '^Trere : >: ^-^
no 2ci'l. as tn the r^.:.: , ^e-
cweei the (^estijiJii of SUV -- . ^^
so&xEo. biEaEfecajate ampJy tfissolves the
gastric macas ^soA is absocbe<l mar-
cfcxti^ied. JfeotraJicitwii t>f . -
actid has been hf'
partly or cor. . . - . . _ -.m-
trie hyperactdity . Ltovrevxar, it "■^;-'''
nevertheless*, be beieiiciaL by j
excessive irritatijon: b-v the gastrtc actd
Ett the ■
catarrh of ciie ;ai:i:ei\ :kv
others biive -' " that • - o^irt
no direct •"■ — th.e -c^., • ■•• "•*
reactic- ■ ■ ---^'^ -■-
\fiew^ -- . .-- ^
some, sue -.ire e^'^re*^ 'i '■*■
tiaxatrve etf ect. Ottce • - : ■ :
bloodL so« ■ carbonate increases the
jf the tatter, though tts r.-
excrenott readers fit tfiffrcttlt ts* ((jfecaiu
a lastitrg: rescttt bbb t&cs respect- "^
of che ortEce cs redttced ■
ir^'T-r^ """creased: whe--
- ij'cii Clvch t*; — ^''er .. ^ .. " :
■<i. sodiora: ._ . • 'ate tr^av" b
fee it arcchangeii
Scilrttni btcarfjorctte alwtEjrs strmtt-
EEfees t&e gttstric seci?etrotts^ Ehe %>-
tiT^, _...-....- iont«i .„„^ ^._ .. ■
so tfett t&ie fuotf cart [©tve t&ie si
acfti birfbce- Ifee (ssKfissbre ac&lfir?- (it
tfte c&yme ' L T&e
(ira^ ftits a ......j.^. . - ■••£ '■'■-
teJir on. tfce fctniy paiix c: -
ever m. secretary iaiSTrfEcxiaiiey- im
fr- ■'•:^st resTrfts- ar^
Qi; ..^.- . - . -. ^: --:;i3nral q£ twx?
6;ottrs before tfee nretr for a i&se of
0:5 QiL- {73 ^srams'i : tixee fcotrrs for
trwrnre fefri-s dose., lavf foar fcomrs for
I • ■ ■• ■ ■' - "— ~~ r— ■•ns-).. Vf— '
sir; , ev^Hi •' : ■
tfee nteaDs. TBae isrvx^ remfeirs t&e
stQniaid&: content alkaEiie smS. amdier
tfre stfimtttttiba of tMs tEte se ■
180 SODIUM (SAJOUS).
cial Kissingen salt). Dose, 80 grains Small amounts of salt have been found
(5.5 Gm.) in 6 fluidounces (200 c.c.) at times to lessen the acidity of the
of water. gastric juice, but the greater palatabil-
Pulzns salis Vichyani factitii effer- ity of food seasoned with salt may
vescens, N. F. (effervescent artificial counteract this Ijy augmenting the re-
Vichy salt). Dose, 57 grains (3.75 flex gastric secretion. The salivary
dm.) in 6 fluidounces (200 c.c.) of flow is increased by salt, partly through
water. reflex action and partly because some
Piilvis salis Vichyani factitii effer- of it is excreted by the salivary glands.
vcsccns cum lithio, N. F. (efifervescent Absorption of ingested hypotonic
artificial Vichy salt with lithium), solutions of salt takes place chiefly
Dos.e, 90 grains (6 Gm.), representing from the intestine, and results in a
14 grains (1 Gm.) of artificial Vichy diluted condition of the blood — hydre-
salt and 5 grains (0.3 Gm.) of lithium mia — which induces diuresis. The flow
citrate. of urine is increased more by direct
PHYSIOLOGICAL ACTION.— saline infusion into the blood than by
Sodium as an element or ion exerts in saline solution (or water) absorbed
moderate amounts, different from po- from the stomach and bowel. Hyper-
tassium, little or no effect upon the tonic salt solution injected into the
tissues of higher animals. That the blood causes marked diuresis through
sodium ion may exert a deleterious ac- absorption of water from the body tis-
tion on some animal cells is shown, sues, but hypertonic salt solution in-
however, by the observation that some gested causes little or no diuresis, as
ova and fish ordinarily inhabiting sea- the salt is only slowly absorbed from
water survive longer when placed in it, and though tending, for a time, to
distilled water than when placed in a increase the total bulk of the blood,
solution of sodium chloride isotonic does not render it hydremic,
with sea-water. More concentrated Sodium hydroxide (caustic soda),
solutions of sodium chloride, in addi- like potassium hydroxide and calcium
tion to a possible ionic poisonous ef- oxide, is a strong caustic, destroying
feet of the kind just described produce tissue by abstraction of water, dissolu-
the effects characteristic of "salt ac- tion of albumin, and saponification of
tion" in general, viz., withdrawal of fats. Similar effects are produced by
water from cells, with corresponding liquor sodii hydroxidi and by soda cum
shrinkage of the latter and, where the calce (N. R).
occasion presents, effects due to irrita- Sodium hypochlorite, official in the
tion, such as vomiting in the case of liquor sod?e chlorinatse or Labarraque's
the stomach. solution, gives off chlorine and pos-
According to the experiments of sesse? the antiseptic, deodorant, and
Miinch, exhibition for a few days of bleaching properties of the latter. It
large quantities of sodium chloride in is decidedly irritating to the tissues,
man causes at first a slight decrease but this property may be reduced,
in excretion (especially renal), with a seemingly without loss of antiseptic
corresponding gain of body weight; power, by the addition of suf^cient
after a time, however, the excretions boric acid to neutralize the free alkali
-ncrease and the weight decreases, in the preparation.
SODIUM (SAJOUS).
181
Sodium acetate, like other salts of
alkalies with the vegetable acids, is
rapidly absorbed and oxidized in the
system to form sodium carbonate,
which increases the alkalinity of the
blood and urine, and causes diuresis.
Over direct ingestion of alkaline car-
bonates or bicarbonates, sodium acetate
and similar salts have the advantage
of not neutrahzing the gastric juice.
Sodium bicarbonate, applied in solu-
tion to mucous membranes, exerts a
soothing effect, and tends to dissolve
thick mucus. It is mildly alkaline, but
the alkalinity of its solutions increases
on standing, because of the loss of
carbon dioxide. Applied in dilute solu-
tion to isolated contractile organs, in-
cluding vessel-walls and ciliated epi-
thelium, it causes for a time, like other
dilute alkalies, increased activity and
tonicity, and in certain protozoa an
increased resistance to asphyxia from
oxygen exclusion; later, the augmented
activity is replaced by depression.
Experiments in dogs have shown
that the alkaline carbonates, adminis-
tered internally, do not influence the
rate of gastric secretion. They tend,
however, to increase gastric motility
by virtue of the carbon dioxide liber-
ated through reaction with the hydro-
chloric acid of the gastric juice, and
may also in themselves, by inducing
slight local irritation, exert a mild
carminative effect, relieving gaseous
distention and the consequent pain.
Five grains (0.3 Gm.) of sodium bi-
carbonate, if completely utilized in the
destruction of the gastric acid, are
capable of neutralizing about 1^
ounces of gastric juice of 0.3 per cent,
strength. Where the stomach contains
no acid, as in the resting period be-
tween the digestion of successive meals,
sodium bicarbonate simply dissolves the
gastric mucus and is absorbed un-
changed. Neutralization of the gastric
acid has been held to reduce pancreatic
secretion, the normal stimulus to the
pancreas resulting from the entrance
of acid into the duodenum having been
partly or completely removed. In gas-
tric hyperacidity, however, it may,
nevertheless, be beneficial by allaying
excessive irritation by the gastric acid
in the duodenum, thereby relieving
catarrh of the latter. Stadelmann and
others have shown that alkalies exert
no direct influence on the secretion or
reaction of the bile, in spite of former
views to the contrary. According to
some, sodium bicarbonate exerts a mild
laxative effect. Once absorbed into the
blood, sodium bicarbonate increases the
alkalinity of the latter, though its rapid
excretion renders it difficult to obtain
a lasting result in this respect. The
acidity of the urine is reduced and its
total output increased; where enough
has been given to render the urine
alkaline, sodium bicarbonate may be
found in it unchanged.
Sodium bicarbonate always stimu-
lates the gastric secretions. In hy-
perchlorhydria it should be given in
large doses some time after meals,
so that the food can leave the stoin-
ach before the excessive acidity of
the chyme has been restored. The
drug has a remarkable soothing ac-
tion on the tardy pain of digestion,
even in secretory insufficiency. In
hypochlorhydria the best results are
obtained with an interval of two
hours before the meal for a dose of
0.5 Gm. (7.5 grains); three hours for
twice this dose, and four hours for
a dose of 5 Gm. (75 grains). Very
small doses can be given even with
the meals. The drug renders the
stomach content alkaline, and under
the stimulation of this the secretions
gradually pour out to neutralize the
alkalinity, and normal acidity is thus
184
SODIUM (SAJOUS).
acetic, citric, or tartaric acid, which
are often available in the form of
vinegar, or lemon-juice. Passage of
a stomach-tube is dangerous, as it
might penetrate the corroded gastric
wall.
Olive oil, lard, white of egg, or
milk, should be given as demulcents.
Morphine may be given to alleviate
the pain. Stimulants may be re-
quired to combat collapse ; external
heat should also be applied under
these circumstances. Later, the pas-
sage of bougies or surgical proced-
ures to overcome stenosis may be
necessary.
SODIUM BICARBONATE AND
CARBONATE.— Sodium bicarbonate
is free of caustic action, but the car-
bonate may corrode tissues when ap-
plied for some time in concentrated
solution. Giving large amounts of
the alkaline carbonates and bicar-
bonates to animals has been observed
to induce a chronic gastroenteric in-
flammation, which may prove fat-al.
Sodium bicarbonate in large doses,
such as 300 grains (20 Gm.) or more
daily, may cause an increase in body
weight, due to retention of chlorides
with resultant water retention, which
may go on to the appearance of
edema. This condition is most likely
to appear during the administration
of the bicarbonate to cachectic dia-
betics with acidosis, but it can be
produced in an experimental way in
normal individuals. L. A. Levison
(Jour. Amer. Med. Assoc, Jan. 23,
1915).
SODIUM CHLORIDE. — Serious
symptoms and frequently death have
resulted from the introduction of a
large quantity of sodium chloride into
the system. Such poisoning occurs
oftenest from the inadvertent use of
a strong salt solution instead of nor-
mal saline solution for proctoclysis or
intravenous infusion, but is reported
also to be a common method of sui-
cide in one of the provinces of China,
a pint or more of saturated salt solu-
tion being ingested for this purpose.
Combs reported a fatal case, with
crenation of the erythrocytes in fresh
blood, in a woman who received about
4 ounces (120 Gm.) of salt in a strong
solution by hypodermoclysis.
The symptoms of sodium chloride
poisoning consist of nausea, vomiting,
diarrhea, fever up to 104° F. (40° C),
delirium or coma, and fatal collapse.
In cases with diminished renal per-
meability and salt retention, as in
nephritis or eclampsia, even normal
saline solution may increase edema
and induce edema of the lungs, or the
v^omiting of fluid rich in chlorides
(Bastedo). Marked edema of the
legs from prolonged use of large
amounts of salt with the meals has
also been reported.
Case of a healthy boy of 5 years
who received an injection of strong
brine as a domestic remedy for
worms. The mother made the mis-
take of putting a pound instead of
a tablespoonful of salt in a quart of
water. In five or ten minutes the
child was taken with pain in the
head, intense thirst, and vomiting,
soon followed by severe purging. In
thirty minutes he had become un-
conscious, and one convulsion fol-
lowed another until death occurred
five hours after the injection. O. H.
Campbell (Jour. Amer. Med. Assoc.
Oct. 5. 1912).
SODIUM NITRATE. — The ni-
trates, in excessive amount, especially
if taken in concentrated form, cause
gastric pain, nausea, vomiting, and
sometimes diarrhea. Blood may be
eliminated with the vomitus and
stools. Either diuresis or oliguria
may be noted. Further symptoms
SODIUM (SAJOUS).
185
are motor weakness, mental dullness,
collapse, and . coma, terminating in
death. Dilute nitrate solutions may
be taken in large amount without
trouble, but the more concentrated
ones induce the symptoms referred to.
SODIUM SULPHATE.— Large
amounts of a strong solution of this
salt cause repeated alvine discharges,
which finally consist chiefly of mu-
cous fluid stained with bile. Serious
poisoning with it is rare.
SODIUM SULPHITE AND
THIOSULPHATE.— Although large
amounts of the sulphites have been
taken by man without the production
of poisoning, symptoms or irritation
of the alimentary tract have been
noted after even small doses. Some
of the irritation of the stomach is as-
cribed to the liberation of sulphurous
acid by the hydrochloric acid of the
gastric juice.
THERAPEUTICS. — Gastrointes-
tinal Disorders. — The alkaline salts of
sodium, especially the bicarbonate,
are used extensively in disorders of
the alimentary canal. Given in the
digestive period, the bicarbonate di-
minishes the secretion of gastric
juice, neutralizes some of the hydro-
chloric acid, and acts as a carmina-
tive by setting free carbon dioxide.
Where organic acids are present, it
may likewise neutralize them, and
by doing so lead to the opening of a
pylorus previously in spasm.
In continuous gastric hyperacidity
and in cases witli gastric fermenta-
tion and resulting "sick headache,"
preparation of the stomach for a meal
may be effected by giving a dose of
sodium bicarbonate an hour before it.
In the fermentation cases coml:)ina-
tion of calomel with it may be ad-
vantageous. For hyperchlorhydria
manifesting itself after meals, the
drug is also very eft'ective, and is
beneficial, especially when taken one
to two hours after the repast. A
combination of sodium carbonate and
magnesium oxide may be even more
grateful, the latter compound exert-
ing, in addition, a local sedative ef-
fect. Where, however, stimulation of
evacuation is particularly desired, an
efl^ervescent mixture of sodium bi-
carbonate, 30 grains (2 Gm.), with
tartaric acid, 10 grains (0.6 Gm.) —
dissolved separately in half a glass-
ful of water, then mixed — is of value.
Such a mixture may also prove
useful in the vomiting attending
acute inflammatory diseases and the
exanthemata.
The early morning acidity of hy-
peracid cases may be prevented by
the exhibition of a dose of sodium
bicarbonate the night before. Mucus
may be removed from the stomach,
preparatory to breakfast, by a dose
taken on arising. In alcoholic gas-
tritis lavage with a dilute sodium bi-
carbonate solution is useful for the
same purpose.
In gastric hyperacidity alkalies
have two indications. They may be
employed in the late pain of hyper-
acidity, but the tendency of the pa-
tient toward abuse of the drug must
not be forgotten, for excessive use
may cause gastritis. The author pre-
fers bismuth subnitrate in large doses
to the alkalies. The alkalies may
also be employed to hasten the di-
gestive process; here the so-called
Vichy cure may likewise prove bene-
ficial. The use of artificial Carlsbad
salt seems, however, of greater
value, the results being more last-
ing. Hayem (Tribune med., xli, 281,
1908).
The prolonged suppression of salt
in the diet reduces pain and vomiting
in conditions of hyperacidity, while
186
SODIUM (SAJOUS).
in other conditions in which the HCl
is deficient the use of salt increases
it and aids digestion greatly. The au-
thor's experiments on a healthy man,
following out L. Mcunicr's technique,
showed that with certain foods, as
meat, the digestion was the same
with or without salt, but with other
foods, such as milk, eggs, and car-
bohydrate foodstuffs, the digestion
was delayed from ten to twenty min-
utes when no salt was given with
them. Thus, in certain subjects and
with certain foodstuffs, the addition
of sodium chloride to the diet favors
the gastric secretion. A. Martinet
(Presse med., Apr. 1, 1908).
In children, where an antacid is re-
quired and constipation is present,
sodium bicarbonate is preferable to
lime-water.
In yeasty vomiting, especially when
sarcinse are present, sodium sulphite
is often of value in doses of from 5
to 20 grains (0.3 to 1.3 Gm.). The
vomiting due to acid fermentation of
starches and sugars may be relieved
by the same salt in doses of from 20
to 60 grains (1.3 to 4 Gm.), or by
sulphurous acid, in doses of from 5
to 60 minims (0.3 to 3.6 c.c), well
diluted).
In cases with dyspeptic pains asso-
ciated with motor insufficiency, E.
Binet recommends the use of two of
the following powders at intervals,
respectively, of one hour and half an
hour before meals, and, if necessary,
at the same intervals afer meals : —
R Sodii bicarbonatis.. gr. xij (0.75 Gm.).
Magnesii oxidi pon-
derosi gr. iv (0.25 Gm.).
Pulveris belladonH'CC
folioruni gr. % (0.01 Gm.).
Pone in chartulam no. j.
Where there is pylorospasm due to
hypersecretion, a powder should be
taken one hour after the meal and re-
peated at one and one-half-hour inter-
vals until the next meal.
In duodenal ulcer sodium bicar-
bonate may give relief when the
"hunger pain" appears.
In catarrhal jaundice, sodium bicar-
bonate, combined with rhubarb, has
been considered especially useful.
The official mixture of rhubarb and
soda may be given.
In chronic hepatic affections good
results have at times followed the use
of the solution of chlorinated soda, in
doses of from ^ to 2 drams (2 to 8
Gm.), diluted in from 4 to 8 ounces
(120 to 240 c.c.) of water. .
In constipation sodium sulphate is
not as often employed as some other
drugs in human beings, though
largely used in veterinary practice, as
it is one of the most irritant of the
saline purges, producing large, watery
stools with considerable griping. The
purgative dose is from ^ to 1 ounce
(7>4 to 30 Gm.). It should be used
with some caution if any intestinal
inflammation be present. It is one of
the constituents of Carlsbad, Hun-
yadi, and similar waters. According
to Maberly, it frequently acts as an
intestinal antiseptic in small doses.
Sodium sulphate is an intestinal
antiseptic. After observation of its
action in dysentery and infantile di-
arrhea, the writer relies almost en-
tirely on it in all septic bowel
complaints. To obtain the antiseptic
action one must avoid doses having
an aperient action. The dose should
begin with about 6 grains (0.4 Gm.)
for a baby under 6 months of age,
increasing up to 1 dram (4 Gm.) for
adults, given every six hours in one
of the flavored waters, such as fen-
nel. Children over 6 months old
seldom exhibit any aperient effects
from doses of 14 to 20 grains (0.9 to
1.3 Gm.). The writer also uses the
drug in typhoid fever; the stools,
SODIUM (SAJOUS).
187
from being loose and fetid, become
more normal in appearance and odor,
and the temperature runs a lower
course. Maberly (Lancet, Nov. 10,
1906).
For diuretic purposes, 4 Gm. (1
dram) of sodium sulphate may be
dissolved in 1 or V/2 liters (quarts)
of v^rater, to be divided into three
doses, one in the early morning, on
a fasting stomach; one in the fore-
noon, and one in the afternoon ; the
water must be sipped slowly. For a
light, non-irritating purgative effect,
5 Gm. (V/i drams) of the salt may
be dissolved in Yz or Y^ liter (quart)
of water, to be divided in two doses,
one in the early morning and one an
hour before the noon meal; it should
be taken warm. For an energetic
purgative action, 25 to 60 Gm. (6 to
15 drams) of sodium sulphate are to
be dissolved in 200 c.c. (6 ounces)
of water, sweetened if desired, or
flavored with lemon, peppermint, or
anise-seed, according to taste, to be
taken at one dose. Alfred Martinet
(Presse med., Aug. 23, 1911).
Physiological salt solution passes
through the gastrointestinal tract
without irritating it or interfering
with osmotic conditions. There is
nothing which passes along so rap-
idly. The writer has patients drink
2 glassfuls of a 0.9 per cent, solution
of sodium chloride twenty minutes
before breakfast. After nine or
twelve minutes defecation followed.
The stomach expels the solution
promptly, and reflexly sets up peris-
talsis throughout the intestinal tract.
The larger the amount ingested the
more rapid the passage. Most min-
eral waters are hypertonic and are
absorbed in the duodenum unless
large quantities are taken. After
drinking the salt solution on an
empty stomach in the morning the
writer has the patient follow it with
a cup of coffee or other appetizing
drink. In atony of the stomach, the
rapid expulsion of the physiological
salt solution makes it a valuable reg-
ulator of the bowels. Best (Med.
Klinik, July 27, 1913).
The use of sodium citrate has been
strongly recommended in the treat-
ment of digestive disorders, especially
in children, as well as in acidosis and
in pneumonia. According to Lacheny,
15 grains (1 Gm.) of the salt allay
dyspeptic pain in the stomach and 23
grains (1.5 Gm.) promptly arrest most
attacks of vomiting.
The chief uses of sodium citrate
in infant feeding are as follows: (1)
for weaning the healthy infant; (2)
for increasing the amount of milk
taken in the twenty-four hours; (3)
for correcting milk dyspepsia, and
(4) for the avoidance of scurvy. It
is not antibacterial. A good propor-
tion is 1 grain (0.065 Gm.) of sodium
citrate to the ounce (30 c.c.) of milk.
Poynton (Brit. Med. Jour., Oct. 21,
1905).
Good results obtained from the use
of sodium citrate added to milk in
infant feeding when gastric disorders,
especially vomiting, exist. When so-
dium citrate is added to milk the
coagulum is less solid and lighter.
This is due to the fact that in the
presence of sodium citrate the cal-
cium salts, especially the chloride,
which augment coagulation, are pre-
cipitated. It is usual to administer
1 to 2 Gm. (15 to 30 grains) a day
to infants. Vomiting due to hypo-
alimentation may derive as much
benefit from its use as that due to
superalimentation. The drug is su-
perior to bicarbonate of sodium in
digestive disturbances in adults, and
does not cause a secondary secretion
of acid in the stomach. Variot
(Tribune med., Oct., 1910).
Sodium citrate facilitates the diges-
tion of milk when a milk diet is be-
ing given, preventing the formation
of large, compact clots where the
fluid is drunk too quickly or in ex-
cessive amounts at one time. Many
cases of infantile dyspepsia yield
when a tablespoonful of a 10-grain
(0.65 Gm.) to the ounce (30 c.c.)
solution of sodium citrate is added
188
SODIUM (SAJOUS).
to each 4-ounce (120 c.c.) bottle of
milk.
Sodium citrate also acts as an al-
kali, is soothing in pyrosis, dimin-
ishes gaseous fermentation, and even
obviates the regurgitation of food.
Even in small doses, it is a good
laxative. In constipation in dyspep-
tics it lessens autointoxication and
obviates mechanical disturbances. In
constipation associated with hepatic
congesion, Huchard frequently ad-
vised its employment, along with
sodium sulphate and bicarbonate: —
IJ Sodii citratis,
Sodii hicarhonatis,
Sodii sulphatis.. . .aa. 3v (40 Gm.).
M. Sig. : One teaspoonful every morn-
ing in a hot infusion.
Plicque (Bull, med., May 31, 1913).
In certain conditions of malnutri-
tion, marasmus, and chronic indiges-
tion in infants and children, Le Bou-
tillier and others have recommended
subcutaneous injections of a dilute
sea-water solution.
In applying the sea-water treat-
ment in infants, the writer followed
the Robert-Simon method, diluting 83
parts of sea-water with 190 parts of
pure spring-water, filtering through
a germ-proof Berkefeld filter, and
putting it up in sterile bottles. The
usual injection sites were just below
the angle of the scapula or in the
gluteal regions, the former being
preferable. The amount injected
varied from 10 to 60 c.c. (2>4 drams
to 2 ounces), the usual dose being
15 to 30 c.c. (^ to 1 ounce), accord-
ing to age and urgency, and from
three times a week to every day for
a short time. Sometimes five or six
injections improved the condition so
much that the patient was discharged.
In other cases the treatment had to
be kept up for several months. There
is improvement in the amount of food
taken within the first two or three
weeks; this is noticeable in older
children suffering from malnutrition
or chronic indigestion. In infants.
distressing colic was invariably re-
lieved within the first two weeks.
The skin, often harsh, dry, and scaly,
cleared up entirely, whether in in-
fants or in older children. The pa-
tients who were losing weight or
stationary, as a rule, gained after the
first few treatments, sometimes as
much as an ounce a day. The sleep
of many patients was markedly im-
proved. The treatment is a useful
adjunct of other methods in the mal-
nutrition of tuberculous disease "t
that following any of the infectious
diseases, T. LeBoutillier (Jour. Amer.
Med. Assoc, Jan. 1, 1910).
In the cyclic vomiting of children,
rectal or oral administration of a 2
per cent, solution of sodium bicar-
bonate is an essential measure where
■ acidosis exists, in conjunction with
the administration of dextrose, seda-
tion of the vomiting reflex by means
of drugs, and exhibition of fluids in
copious amounts.
In cancer of the stomach the use of
sodium chlorate has, in some cases,
been followed by good results. The
initial dose recommended by Brissaud
is 2 drams (8 Gm.) daily, in divided
doses ; this is gradually increased un-
til 4 drams (16 Gm.) are taken. If
albuminuria be present or develop,
the drug is contraindicated.
In mercurial stomatitis, aphthae,
mucous patches, and ulcers of the
tonsils, sodium sulphite in 1 to 8
solution may be applied with a cot-
ton pledget, or in the form of spray.
Calomenopoulo has emphasized the
utility of sodium chlorate in mercurial
stomatitis. He also noticed that so-
dium chlorate in large doses reduced
intolerance to potassium iodide where
this drug was being taken in full
doses for syphilis.
Seatworms {Oxyuris vermicularis)
may be dislodged from the rectum by
SODIUM (SAJOUS).
189
injection of a solution of the chloride,
and, with them, the intense itching.
The injections should be given every
morning, then every two to four
evenings, with the buttocks ele-
vated or in the Knee-chest posture
until all evidence of the worms has
disappeared.
In dysentery the use of sodium ni-
trate in dram (4 Gm.) doses, freely
diluted, every three hours, has been
recommended.
Cutaneous Disorders. — In acute
eczema, when there is much serous
discharge, the following application
is efficient: Sodium carbonate, ^
dram (2 Gm.) ; water, 1 pint (500
c.c). The solution may be made
stronger in old cases where the skin
is much thickened. When the weep-
ing has ceased and mere desquama-
tion remains, the alkali ceases toi be
of use.
The pruritus of eczema, lichen,
urticaria, dermatitis, burns, and frost-
bite may be relieved by applications
of the following: Sodium bicarbonate,
3 drams (12 Gm.) ; glycerin and dis-
tilled extract of witchhazel, of each,
3 ounces (90 c.c). The itching of
urticaria and lichen will often yield
to a 1 : 100 solution of sodium car-
bonate, applied with a sponge or
mop.
Poison-ivy eruption and other
forms of pruritus may be similarly
soothed by sodium hyposulphite in
solution (1 to 16), a solution of the
bicarbonate, or by the solution of
chlorinated soda, diluted 1 to 32.
In parasitic skin diseases, espe-
cially those due to the tricophyton
fungus, as pityriasis versicolor, the
hyposulphite (1 to 8) in solution or
ointment is valuable. Startin has
recommended the following: Sodium
hyposulphite, 3 ounces (90 Gm.) ; di-
lute sulphurous acid, ^ ounce (15
c.c.) ; water, enough to make 1 pint
(500 c.c). In tinea versicolor and
pruritus vulvae Fox found the follow-
ing useful : Sodium hyposulphite, 4
drams (16 Gm.) ; glycerin, 2 drams
(8 Gm.) ; water, enough to make 6
ounces (180 c.c).
In scabies also the hyposulphite
has been used successfully. After the
morning bath apply the hyposulphite
in solution (1 to 1) to the affected
part and allow it to dry on the skin.
At night bathe with the following
lotion, which may be diluted if
found too strong: Dilute hydrochloric
acid, 4 ounces (120 c.c) ; distilled
water, 6 ounces (180 c.c.) (Ohmann-
Dumesnil).
For the removal of freckles, sun-
bum, and tan the following lotion
may be used : Sodium chloride, 2
drams (8 Gm.) ; potassium carbonate,
3 drams (12 Gm.) ; rose-water, 8
ounces (240 c.c.) ; orange-flower-
water, 2 ounces (60 c.c). The in-
flammation of sunburn may be sub-
dued by applications of sodium bicar-
bonate in solution.
In hyperidrosis of the feet and
axillae a solution of the carbonate
freely applied locally will remove the
fetor and diminish the secretion of
sweat.
In burns and scalds sodium bicar-
bonate in powder or in solution re-
lieves the pain and soreness very
promptly. It may also be applied
with advantage to insect bites.
The carbonate is used externally
when it is desirable to soften or re-
move scaly or scabby accumulations
upon the skin, as in certain forms of
eczema, plica polonica, etc.
In tuberculous ulcers and in psoria-
190
SODIUM (SAJOUS).
sis, g^ood results have at times been
secured with hypodermic injections
of diluted sca-ivatcr, as orijuinally
su.G^n;-ested by Robert-Simon and
Quinton.
Genitourinary Disorders. — Irrita-
tion of the urinary })assa£;;"es due to
an excess of acid may be allayed by
sodium bicarbonate in doses of 10 to
20 g-rains (0.6 to 1.3 Gm.), given in
a glass of water, every four hours.
In cystitis a 1 per cent, solution of
the bicarbonate may be used to wash
out the bladder when an acid condi-
tion of that viscus exists.
Some relief is afforded in gonorrhea
by injections of a 1 per cent, solution
of the bicarbonate.
In malarial hematuria sodium hy-
posulphite is given with advantage in
doses of from 10 to 30 grains (0.6 to
2.0 Gm.), every four hours. Its mode
of action is unknown.
Fischer's solution, containing 10
Gm. (150 grains) of sodium car-
bonate (crystallized) and 14 Gm. (210
grains) of sodium chloride to the liter
(quart) of water, has been used in-
travenously in amounts up to 2 liters
(quarts) for the relief of anuria in
scarlet fever, eclampsia, Asiatic chol-
era, etc. In less urgent cases of im-
paired renal function, including cases
of chronic nephritis, the sodium bicar-
bonate may be increased to 15 to 30
Gm. (225 to 450 grains) in the liter,
and the solution given per rectum by
the drop method.
Sodium chloride having long been
known as a powerful diuretic, the
writer used it as a last resort in ad-
vanced nephritis, and obtained striking
benefit after a prolonged period on a
salt-free diet. When no benefit fol-
lows the salt-free diet, a single large
amount of sodium chloride, 1 to 3
days during the week, may induce
marked diuresis and considerable clin-
ical improvcnunt. Polag (Schweizer.
mcd. Woch., i, 29, 1920).
Laryngologic and Respiratory Dis-
orders.— In asthma the use of potas-
sium nitrate in 3- or 4- grain (0.2 or
0.26 Gm.) doses has been highly
commended. The drug is probably,
in part, changed to a nitrite in the
system, and acts as such.
In pulmonary hemorrhage the ad-
ministration of dry salt is a popular
remedy.
Use of salt by the mouth or in
infusion recommended to control
hemorrhage. Salt enhances the co-
agulating power of the blood in the
living subject, though not in the test-
tube. This may be due to the mobi-
lization of thrombokinase stored up
in the tissues. In 29 cases of hem-
optysis the writer obtained excellent
results by giving 75 grains (5 Gm.)
of sodium chloride by the mouth,
coagulability being much increased
thereby for an hour to an hour and
a half. The effects become evident
in a few minutes. If the tendency
to hemorrhage returns later, the dose
of salt is repeated, or potassium bro-
mide substituted in the dose of 45
grains (3 Gm.), the bromide having,
further, a sedative action. In the most
urgent cases the use of sodium chlo-
ride and potassium bromide, in full
doses, may be combined. R. von den
Velden (Deut. med. Woch., Feb. 4,
1909).
In capillary hemorrhages, including
capillary hemoptysis, in the hemor-
rhagic diathesis, and in epistaxis and
metrorrhagia, Reverdin claims 2-grain
(0.13 Gm.) doses of sodium sulphate
every hour to be of great value. The
drug must be given by mouth or
intravenously, not hypodermically.
It is believed by him to increase the
coagulabilitv of the blood.
In acute tonsillitis, catarrhal condi-
tions, bronchitis, etc., sodium l)icar-
SODIUM (SAJOUS). 191
bonate in solution may be combined Solutions of sodium bicarbonate are
with hamamelis, belladonna, or other extensively used in catarrhal condi-
remedial agent. According to Bulk- tions to soften and remove dried
ley, coryza may be successfully secretions and thickened mucus. Do-
treated by giving 20 to 30 grains bclVs solution (sodium bicarbonate and
(1.3 to 2 Gm.) of the sodium bicar- borax, of each, 2 drams — 8 Gm. ;
bonate in 2 or 3 ounces (60 or 90 c.c.) phenol, 24 grains — 1.5 Gm. ; glycerin,
of water, every half-hour, for three 14 drams — 56 Gm. ; water, 1 pint —
doses, with a fourth dose an hour 500 c.c.) is largely used for this pur-
from the last one. Two to four pose. Pynchon has recommended the
hours are next allowed to elapse, and following as better : Sodium bicar-
the four doses are then repeated if bonate and borax, of each, 2 ounces
there seems to be necessity, as is fre- (60 Gm.) ; listerin (liquor antisepti-
quently the case. After waiting two cus, U. S. P.), 8 ounces (240 c.c);
to four hours more the same course glycerin, 1^ pints (750 c.c.) ; of this
may be taken again. To be promptly add 1 ounce (30 Gm.) to 1 pint (500
effective the measure should be begun c.c.) of water.
with the earliest indications of coryza Gynecological and Puerperal Disor-
and sneezing, when it rarely fails to ders. — Leucorrhea, when dependent
break up the cold. upon an increased secretion of the
K. E. Kellogg points out that in cervical glands, frequently yields to
hay fever marked relief from the injections of a 1 per cent, solution of
rhinitis symptoms follows the taking the bicarbonate. This secretion is
of sodium bicarbonate in 1-dram (4 strongly alkaline, and is checked on
Gm.) doses three times a day. The the general principle that alkalies
drug appears to have a desensitizing check alkaline secretions.
action on the mucous membranes. In puerperal metritis the solution
In a few cases he found it necessary of chlorinated soda (1 part to 10 or
to supplement the treatment with a 12 of water) has been used as an
nasal spray of sodium bicarbonate antiseptic injection. In the same
solution. strength it may be used as a vaginal
In affections of the throat and douche when the lochial discharge
fauces, sodium chlorate is a better becomes fetid. It is also a useful
and safer remedy than the potassium injection in simple and gonorrheal
salt. vaginitis.
In malignant forms of sore throat A hypertonic solution of 4 drams
and in diphtheria the official solution (16 Gm.) of sodium chloride and >4
^r ^1,1^,-;,,^+ A A^ rj/ A. o j^^^„ dram. (2 Gm.) of sodium citrate to
of chlormated soda (% to 2 drams — , . .r^r. n r i
_ ^ ^ . . r. the pint (500 c.c.) of water proved
2 to 8 Gm.—m water, 4 to 8 ounces— ^^^ effective vaginal douche in all
120 to 240 c.c.) has been used as a inflammatory diseases of women and
gargle. Sodium sulphite in solutiotl in septic conditions, giving better
(1 to 8) may be used as a gargle, results than the customary antiseptic
spray, or local application in similar douches. In infected puerperal le-
... T , , , 1 • sions of the genital tract healthy
conditions. It has also been used in- , ^. „ ^^^„^^a ;„ -, f«,„
granulation was secured in a tew
ternally in combination with sulphur ^ays. After clearing out the uterus
and calomel. in puerperal sepsis and douching it
192
SODIUM (SAJOUS).
with the hypertonic saline solution,
a few tablets of salt left in the uter-
ine cavity cause the flooding of any
remaining organisms with the serum
drawn out to dissolve the salt and
materially hasten recovery. All con-
ditions producing pelvic congestion
responded well to the hypertonic
douches. Enemata of water contain-
ing from 3 to 6 or 8 drams (12 to 24
or 32 Gm.) of salt to the pint (500
c.c.) proved effective in emptying
the bowel in eclampsia and other
conditions requiring a watery evacu-
ation for the removal of toxic ma-
terial. Clifford White (Lancet, Oct.
30, 1915).
Constitutional Disorders. — Acute
rheumatism, though usually best
treated with the salicylates (see
Salicylic Acid), is also amenable to
the action of the alkalies. Sodium
bicarbonate is of great service in
allaying the pain and soreness of the
joints when given internally in doses
of from 15 to 30 grains (1 to 2 Gm.)
every four hours. It may also be
used in solution as a lotion, applied
around the joints on lint or cloths.
Sodium nitrate in solution (1 to 3)
has been used externally in like man-
ner. Sodium acetate has been given
in acute rehumatism and gout, but its
value is less than that of the corre-
sponding potassium salt.
In conditions associated with acido-
sis, including diabetes mellitus, so-
dium bicarbonate or carbonate have
been extensively used. To act as a
blood alkalinizer sodium bicarbonate
should be given shortly before meals,
when no acid to neutralize it is pres-
ent in the stomach. In diabetic coma,
delayed chloroform poisoning, and
similar severe states of acidosis, doses
as large as ^ ounce (15 Gm.) of
the bicarbonate have been given by
mouth, or by the rectal drop method,
amounts up to 1% ounces (50 Gm.)
a day, in a 3 per cent, solution in
water. At times, gratifying results
have been obtained.
Sodium citrate advocated in place
of sodium bicarbonate for use in
acidosis. It is practically tasteless,
and may be added to the food or
given in water and lemon-juice. Al-
though the author has given as much
as l}/2 ounces (45 Gm.) a day, it
causes much less digestive disturb-
ance than the bicarbonate, and diar-
rhea never followed its administra-
tion. Lichtwitz (Therap. Monat.,
XXV, nu. 81, 1911).
The hypodermic use of sodium bi-
carbonate solutions has fallen into
disrepute on account of their ex-
tremely irritating properties. This is
because during sterilization this salt
is largely converted into sodium car-
bonate. The latter may be recon-
verted into sodium bicarbonate if
carbonic acid gas is allowed to
bubble through the sterilized solu-
tion. The latter is then well borne
both subcutaneously and intraven-
ously, and is indicated in diabetic
coma. A 4 per cent, solution should
be used. The writer advocates the
preparation of such solutions in
sealed flasks with a carbonic acid
atmosphere. Magnus-Levy (Med.
Klinik, S. 2001, 1914).
Vorschiitz has called attention to
the value of an alkali in whipping up
the body cells to proper metabolism
and elaboration of protective sub-
stances. A deficiency of alkali, he
asserts, may be responsible for defec-
tive antibody production. In cases
with severe septic processes, osteo-
myelitis, scarlatinal nephritis with
abscess, etc., he witnessed good ef-
fects from having the patients drink
during the day a bottle of Seltzer-
water, in which 150 to 300 grains (10
to 20 Gm.) of sodium bicarbonate had
been dissolved. Although in some
SODIUM (SAJOUS).
193
cases gastric discomfort necessitated
at times svispension of the treatment
for a day or two, some patients took
the doses mentioned for weeks with-
out disturbance, and all cases thus
treated recovered.
Surgical Disorders. — In fractures
and sprains a solution of sodium sili-
cate constitutes a valuable dressing,
as it rapidly becomes hard and im-
movable when painted over the band-
ages and thus forms an immovable
splint which is cleaner than plaster
of Paris and equally effective.
Morbid growths, warts, etc., may
be removed by applications of caustic
soda or of London paste.
Wright's solution, composed of 4
per cent, sodium chloride and 1 per
cent, sodium citrate in water, is
useful in the treatment of infected
cold more of the hot solution is
poured over the whole dressing. The
solution is contraindicated if there is
a tendency to persistent oozing of
blood from the wound, and when
protective adhesions are desirable, as
in certain abdominal wounds just
after operation. The solution should
be used only for the first thirty-six
to seventy-two hours after operation,
during the acute stage of the mflam-
mation. If used longer it leads to
maceration and indolence in healing.
L. R. G. Crandon (Annals of Surg.,
Oct., 1910).
Wright's citrated isotonic solution
(sodium citrate, 0.5; sodium chloride,
3.0; distilled water, 100) used with
great satisfaction in the treatment
of wounds. G. K. Dickinson (Med.
Rec, June 20, 1914).
Foul ulcers, sinuses, etc., may be
cleansed with liquor sodse chlorinatae,
diluted in the proportion of ^ to 4
wounds, abscesses, etc. The citrate, drams (2 to 16 c.c.) to 8 ounces (250
by precipitating the calcium salts in c.c.) of water. In military practice
the lymph, prevents coagulation and a 3^ per cent, solution of sodium hy-
insures free exit of lymph discharge, pochlorite has been extensively used
The chloride, in hypertonic solution, for checking infection in wounds,
hastens the flow of lymph by osmosis, Dakin's solution is prepared by dis-
thus antagonizing bacterial develop- solving, in 10 liters (quarts) of tap-
ment, and is itself antiseptic owing to water, 140 Gm. (4^^ ounces) of dried
its hypertonicity. sodium carbonate (or 400 Gm. — 13
In using Wright's solution for ounces — of the crystalline salt) and
drainage, the abscess is opened by a 200 Gm. (6% ounces) of good quality
calcium chloride. The mixture is well
shaken up and after half an hour the
clear liquid separated by siphonage,
filtered through cotton, and 40 Gm.
(1% ounces) of boric acid added. In
Carrel's technique of wound treat-
ment, rubber tubes surrounded by an
absorbent, spongy material are car-
ried to the bottom of the wound and
in each of its recesses, and Dakin's
solution is injected into the tubes at
one or two-hour intervals, or, better,
introduced by continuous instillation
by the drop method.
wound as small as will allow the
cavity to be wiped out, or thor-
oughly emptied by expression. The
surrounding skin is thoroughly
cleaned with 70 per cent, alcohol
and smeared with boric acid or
eucalyptus petrolatum. If the skin
tension closes the lips of the wound
a bit of rubber dam may be put in.
The wound is covered with a large
pad of gauze or of absorbent cotton
covered with gauze, dripping wet
with hot salt and sodium citrate
solution. The part is put at rest.
* Outside the dressing may Ijc applied
a hot flaxseed poultice or a hot-water
bottle. As often as the dressing gets
8—13
194
SODIUM (SAJOUS).
Intravenous infusion of 3 to 5 c.c.
(48 to 80 minims) of a 5 per cent,
salt solution practised with the best
results before operations in which
parenchymatous hemorrhage is feared
or when the blood coagulates less
readily than normal. The measure
is advised in prophylaxis or during
the operation, repeating it every half-
hour as needed. Von den Velden
(Zentralbl. f. Chir., May 21, 1910).
Instruments, especially if plated,
when boiled in a solution of sodium
carbonate or bicarbonate come out
covered with a white scum, are slip-
pery, and less quickly dried, and are
likely to turn black, especially if they
have any blood left on them. The
writer recommends, instead, the use
of sodium hydroxide, which has not
these disadvantages. About 38 grains
(2.5 Gm.) or Y^ inch of stick caustic
to a quart (liter) of water makes the
proper solution. I. M. Ileller (Jour.
Amer. Med. Assoc, Aug. 26, 1911).
CHLORIDES IN URINE.— These con-
sist chiefly of sodium chloride, with a
small amount of potassium and ammonium
chlorides. The healthy adult excretes
from 10 to 16 grams of chlorides in 24
hours. The chlorides are increased nor-
mally, by increased ingestion of salt, by
al^undant drinking of water, and by active
exercise; abnormally, in the first few days
after the crisis of acute febrile diseases,
gradually increasing as the disease abates;
in diabetes insipidus; in dropsy after
diuresis has set in. The chlorides are
decreased normally during repose; abnor-
mally, in all acute febrile conditions (espe-
cially with serous exudations) up to the
crisis, when they may disappear; in pneu-
moniia their absence always indicates a
serious condition; in diarrhea; in chronic
conditions with impaired digestion and
dropsy; during the formation of large exu-
dations; in acute and chronic diseases of
the kidnej'S with albuminuria; in chronic
diseases. A decided diminution or ab-
sence of chlorides in a febrile condition
strongly suggests pneumonia.
Test for Chlorides. — Place 2 drams of
urine in a test-tube, acidify with 10 or 12
drops of nitric acid, C. P., and carefully
add 1 drop of silver nitrate solution
(1 to 8). If the amount of chlorides be
about normal, this drop will form a whit-
ish globule, a solid white ring or one or
more compact, whitish, flocculent lumps,
and will settle to the bottom. If the chlo-
rides are diminished, there will be only
some cloudiness. (Jne may use a speci-
men of normal urine in another test-tube
as control. When the exact quantity of
chlorides is desired, one must resort to
quantitative titration, the technique of
which may be found in larger treatises on
Uranalysis.
SALINE SOLUTION.— Prepara-
tion.— As ordinarily prepared, "nor-
mal" saline solution is of 0.8 to 0.9
per cent, strength. For the prepara-
tion of a sterile solution of this type,
sterile sodium chloride may be dis-
solved in sterile water in the ratio of
1 dram (4 Gm.) of the salt to 1 pint
(roughly 500 c.c.) of water; or, the
solution may be sterilized after the
salt has been dissolved. The solution
should then be filtered into flasks, and
these plugged with non-absorbent cot-
ton and sterilized in toto.
Hypertonic sodium chloride solu-
tions are at times used, as in the
hypertonic saline treatment of Asiatic
cholera devised by Rogers, in which
1.2 or 1.6 per cent, solutions of the
salt are employed. (See Cholera.)
Physiological Action and Uses. —
Introduction of normal saline solu-
tion into the system may be of value
in a variety of ways. In hemorrhage
and in depleted states, such as that
arising in cholera, it is of assistance
to restore the blood volume to nor-
mal, thereby not only favoring better
distribution of blood to the periph-
eral parts of the body, but also im-
proving heart action by allowing the
organ to contract under more normal
mechanical conditions. In toxe.mic
states, saline solution is of value to
promote renal activity and therewith
SODIUM (SAJOUS).
195
elimination of toxic material. Where
the blood-pressure is low, a small sa-
line infusion containing a moderate
amount of epinephrin is of great
value, though unless the administra-
tion be continued the effect soon
wears off through filtration of the
solution from the vessels into the tis-
sues. (Large saline infusions under
these conditions merely favor the pro-
duction of edema.) Saline infusions
are also of value for the relief of
thirst.
Absorption of saline solution, how-
ever given, is generally rapid. In
saline hypodermoclysis a pint of solu-
tion may be absorbed within ten or
fifteen minutes, though at times
marked circulatory weakness greatly
delays the process. After hemor-
rhage, especially rapid absorption oc-
curs from the bowel.
Modes of Administration. — Among
the various routes available are: (1)
the rectal ; (2) the subcutaneous ; (3)
the intravenous ; and (4) the intra-
peritoneal.
(1) Saline enteroclysis (proctocly-
sis ; rectal infusion) is advantageous
in that the slight pain entailed in the
insertion of a needle through the skin
is avoided, and that the use of a sterile
solution is not necessary. The older
method of applying the procedure
consists merely in passing into the
rectum a pint to a quart of saline solu-
tion at 110° F. through a small cathe-
ter, twenty to thirty minutes being al-
lowed for its entrance into the bowel.
The measure may be repeated at four-
hour intervals as long as the necessity
for saline administration persists. An
improved procedure is that recom-
mended by John B. Murphy, in which
precise adjustment of the flow of
saline solution to the absorptive
power of the bowel is sought. An
excellent description of Murphy's
technique of proctoclysis, kindly
furnished us bv Dr. Richard L.
Stoddard, of Rochester, N. Y., is
subjoined : —
Cleansing enemas, to the extent of emp-
tying the intestinal tract of fecal matter,
are necessary before beginning the proc-
toclysis treatment. Thorough elimination
of all formed feces from the intestinal
tract during the preoperative preparation
is of paramount importance.
The saline solution is made by adding
1 dram (4 Gm.) each of sodium chloride
and calcium chloride to each pint (500 c.c)
of hot water. The solution must be main-
tained at a temperature per rectum of 100°
to 110° F.
The average quantity is \y2 to 2 pint3
(250 to 1000 c.c.) every two hours. The
quantity to be given depends upon the
severity of the case, the age of the pa-
tient, and the development of an edema.
The average twenty-four-hour quantity is
18 pints. In a child of 11 years (a patient
of Dr. Murphy's) 30 pints were adminis-
tered in twenty-four hours. Murphy
states that "less than 8 pints in twenty-
four hours is of very little value from a
therapeutic standpoint."
The base of the saline solution container
should be elevated sufficiently — 2, 4, or 6
inches — above the buttocks of the patient
to allow 1^ to 2 pints of the solution to
flow into the rectum in from forty to sixty
minutes. The rapidity of the tlow should
never be controlled by the use of forceps,
clamps, knots, or faucets, in connection
with the tubing. The height of the con-
tainer must always control the hydrostatic
pressure, which should average 4 to 6
inches, and not exceed 15 inches.
The patient is placed in the Fowler
position, and the proctoclysis continued
for two or three days, and sometimes five
or six days. Too much solution after the
third, fourth, or fifth day is indicated by
edema of the ankles, hands, and even the
face, and occasionally i)y threatened heart-
failure. The solution should then be dis-
continued until the circulatory equilibrium
is restored, when the treatment may be
196
SODIUM (SAJOUS).
repeated if indicated. The Fowler posi-
tion, being uncomfortable for many pa-
tients, need be used only in exceptional
cases where abdominal drainage is neces-
sary for twenty-four to forty-eighth hourg.
An excellent and comfortable substitute
for the Fowler position is to raise the
head of the bed 12 to 18 inches.
A medium-sized hard-rubber vaginal
douche tube, with several %- to %-inch
openings, makes a useful rectal tube,
which must be flexed at an obtuse angle
2 or 3 inches from its tip. The rectal
tube will cause no inconvenience if so
strapped to the thigh as not to press on
the posterior wall of the rectum. Fre-
quent changing of the rectal tube, as re-
moving and inserting, or an improper posi-
tion of the tube, or a too rapid flow of
the solution into the rectum, are each and
all very annoying to the patient, and soon
produce an irritation of both the anus and
rectum, resulting in partial or complete
evacuation of the saline solution.
When the patient strains during the act
or vomiting, coughing, or sneezing, or
wishes to expel gas or fluid, provision
should always be made for a sudden re-
turn of the fluid through the rectal tube
and rubber tubing into the saline solution.
For this important purpose, one should
use a medium-sized rectal tube with the
openings as described; avoid attempting
to control or govern the rapidity of the
flow by the use of clamps or faucets,
and also avoid overdoing the hydrostatic
pressure.
If the rectum is not in an irritated con-
dition from surgical interference, or other-
wise, success in the early administration
of large quantities of saline solution will
be had with the above technique.
In case an elaborate and electrically
heated solution container is not at hand,
an ordinary douche-can may be employed,
and may be maintained at the desired
temperature by first immersing a bath
thermometer in the saline solution, and
then surrounding the container with bot-
tles filled with boiling water, or immersing
one or two bottles in the solution. To
further retain the heat, the whole ap-
paratus, bottles and container, may be
wrapped in a warm woolen blanket. By
immersing a 16-candle-power electric-light
globe and a thermometer in the saline
solution, the desired temperature can be
more easily maintained.
For the past three years Dr. Stod-
dard has been using the Ny lander
electric saline heater, which correctly
regulates the temperature. He has
thoroughly tested the Murphy method
of proctoclysis in peritonitis, typhoid,
uremia, diphtheria, pneumonia, shock
from hemorrhage, and local and gen-
eral septicemia, and has found it of
inestimable value, especially if used
early and before the heart has been
badly affected by the intoxication.
In lobar pneumonia proctoclysis
with hot tap-water was usually fol-
lowed in a few hours by abatement
of the signs of toxemia and mental
improvement. In typhoid fever bene-
fit was also noted. In obstinate cases
of delirium tremens the mental state
rapidly cleared up. In 4 cases of
scarlet fever, 2 very severe, excellent
results were obtained. The casts and
albumin found in the urine early in
the disease disappeared before the
patients left their beds. In the inter-
current febrile, "grippal" attacks of
pulmonary tuberculosis, the comfort
of the patient was greatly increased
and the invasion apparently cut short.
In the sudden flooding of the sys-
tem with toxins from confined pus
which not rarely occurs in tuber-
culous subjects, remarkable ameliora-
tion of the symptoms may follow
saline proctoclysis. Henry Sewall
(Amer. Jour. Med. Sci., Oct., 1910).
All patients show less rectal irrita-
tion to proctoclj'sis if given a saline
enema before the operation. Patients
given water by rectum absorb nearly
400 c.c. more in the twenty-four
hours than do patients given salt
solution, the average for the former
being 2444 c.c, and for the latter
2041 c.c. Patients given salt solution
by rectum require nearly twice as
much water by mouth to relieve
thirst — 696 c.c. in the first twenty-
four hours, as against 332 c.c. The
SODIUM (SAJOUS).
197
amount of urine is practically the
same in the two classes of cases. In
drainage cases more fluid may be
taken by rectum than in laparotomies
closed without drainage. Proctocly-
sis should be employed more fre-
quently, and in all classes of cases
in which it is possible. Care should
be taken to prevent "water-logging"
of the system, this applying to both
salt and water. In peritonitis cases
with drainage, the patient can take
four or five times as much fluid by
rectum as in other conditions. H. H.
Trout (Jour. Amer. Med. Assoc,
May 4, 1912).
A new device which consists in
placing a two-quart heating bag near
the patient's rectum, through which
the salt solution pipe passes as in a
hot-water bath, prevents the great
loss of heat from the tube, as in
other methods. In this method the
temperature of the saline as it enters
the rectum at first, when the heating
bag has just been filled, is about 108°
F., from which it drops gradually in
an hour and a half to 98°, when the
heating bag is refilled at 140° F. and
the rectal temperature returns to
108° F. G. H. Tuttle (Inter. Jour, of
Surg., June, 1913).
Proctoclysis method applied to in-
fants in place of subcutaneous saline
injection. Tolerance was perfect,
even in the youngest. Fifty or 100
c.c. of isotonic saline solution or 4
per cent, solution of sugar is ab-
sorbed as rapidly as by subcutaneous
injection. Excellent results obtained
in children of all ages with gastro-
enteritis, cyclic vomiting, acute ali-
mentary anaphylaxis, and typhoid
fever. In some cases a little epi-
nephrin was added. The latter was
more effectual by rectum than by
mouth. Lesne (Bull, de la Soc. de
Pediat., Oct., 1913).
Saline proctoclysis by the drop
method gives in typhoid fever results
as good as, if not superior to, those
of the cold-bath treatment. In the
lung complications of typhoid fever,
dyspnea is relieved and the physical
signs of lung condensation caused to
disappear by the measure. Even in
acute, frank pneumonia, the proced-
ure at once reduces the dyspnea and
liquefies the secretions. The heart is
quieted, marked diuresis supervenes,
and the crisis ordinarily occurs on
the fifth day, though the physical
signs persist a few days longer. P.
E. Weil (Presse med., Feb. 14, 1916).
(2) Saline hypodermoclysis (sub-
cutaneous infusion), while usually
highly efficient, is somewhat painful.
Careful asepsis is required, and care
must be taken not to introduce too
much sokition in a single area, lest
the prolonged anemia of the tissues
lesuh in their devitalization and
sloughing. The method is especially
indicated where the emergency is not
such as to require intravenous infu-
sion but the rectal route is unavail-
able because the bowel is too irritable
or for some other reason.
Hypodermoclysis may be practised un-
der the breast, in the loose tissue over the
pectoral muscle, on the posterior or inner
aspects of the thighs, beneath the ab-
dominal skin, including the iliolumbar
regions, or between the scapulae. The
reservoir for the solution is usually of
glass, preferably graduated. The needle
should be long and preferably of a large
caliber, such as 1 to 2 millimeters, for
although a small hypodermic needle may
be successfully used, greater hydrostatic
pressure is then required and the solution
cools more as it descends through the
tube, necessitating an original tempera-
ture of 110° C, as against 105° C. if the
aspirating needle is used. The entire ap-
paratus should have been sterilized. Be-
fore the infusion is given, the breast, in
the case of women, is carefully disin-
fected. It is then raised, and the needle,
with the fluid flowing from it, gently in-
serted into the cellular tissue beneath the
organ. The pain of the puncture may be
avoided with ethyl chloride. Where ele-
vation of the reservoir is insufificient to
maintain the flow, or the latter stops some
1 98
SODIUM (SAJOUS).
time after, withdrawing the needle slightly
or rotating it will usually start the stream
again. If not, the fluid can be forced in
by anointing one hand and the tube with
petrolatum, and stripping the tube down-
ward between the lingsers. Seven hundred
cubic centimeters of fluid (lyi pints) can
be injected under each breast. After com-
pletion of the procedure the puncture can
be closed with rubber tissue or adhesive
plaster.
Absorption from hypodermoclysis where
the general circulation is markedly im-
paired can be hastened by the addition,
where possible, of enteroclysis, or even a
simple hot saline enema (R. C. Kemp).
Gentle local massage also hastens it.
Salt solution for therapeutic pur-
poses may be injected into the pre-
vesical space of Retzius. This space
is roomy, the connective tissue is
loose, and can easily hold one liter
(quart) of solution. The needle is
inserted just above the symphysis
pubis, and pushed along the rear wall
of the latter. In a large experience,
puncture of the bladder never oc-
curred. The author uses a fairly
large needle. One is thus able to
inject a liter of solution in eight to
nine minutes. D. Schoute (Zentralbl.
f. Chir., July 6, 1912).
For hypodermoclysis the writer
uses a large silver cannula from a
Southey tube apparatus, connected
with a large glass funnnel by means
of a tapered glass tube and a section
of Southey's rubber tubing. This is
all readily portable and readily ster-
ilized by boiling. In administering
the saline the anterior axillary fold
is grasped firmly and drawn out-
ward. The trocar with cannula is
then passed into the skin in a direc-
tion perpendicular to the chest and
pushed through the axillary fold, so
that its point emerges within the
■ axilla. The trocar is then removed
and the cannula is pushed outward
until its shoulder is flush with the
skin. The fluid emerging from this
cannula squirts in all directions. It
is absorbed so rapidly that one can
inject a quart into the tissues in
twenty minutes without any material
swelling occurring. E. M. Wood-
man (Brit. Med. Jour., Feb. 8, 1913).
(3) Intravenous saline infusion is
indicated in the more urgent emer-
gencies, e. g., after very abundant
hemorrhage; in cases of shock; where
prompt elimination of toxic material
from the blood is desired, as in de-
lirium tremens, gas poisoning, and
septicemia, and where anuria has de-
veloped, the rise in blood-pressure
attending intravenous infusion caus-
ing a resumption of renal function.
The apparatus required comprises some
.species of graduated reservoir for the
saline solution, a connecting rubber tube
with pinchcock, and a cannula for inser-
tion into the vessel. A slightly curved
cannula is to be preferred, facilitating
maintenance in the lumen of the vessel.
In emergencies the glass portion of a
medicine dropper may be substituted. As
in hypodermoclysis, the apparatus and
solution used should be sterile. The nor-
mal saline solution should be placed in
the reservoir at a temperature of 120° F.
Another useful form of apparatus com-
prises a large flask, arranged like the ordi-
nary wash bottle, with two glass tubes,
one short and the other long, entering it
through the stopper. The longer glass
tube, dipping into the contained saline
solution, is connected by tubing with the
infusion cannula, while to the other tube
a rubber pressure bulb is attached. Pres-
sure upon this bulb forces air into the
flask, and hence the saline solution into
the vein. The temperature of the solution
in the flask may be maintained by placing
it in a large jar partly filled with hot
water.
Preparation of the patient consists in
placing a constricting bandage around the
upper arm, tightly enough to obstruct the
venous return flow, thus distending and
rendering easily visible the vein to be
employed, usually the median basilic or
median cephalic at the bend of the elbow,
applying alcohol or tincture of iodine at
the latter area, and exposing the vein,
under aseptic precautions, for a distance
SODIUM (SAJOUS).
199
of about one inch. After passing two
ligatures, untied, round the vessel, a small
valve-shaped opening, the flap of vessel
raised pointing distally, is made v^^ith
pointed scissors, and the cannula, well
filled with solution and free of air-bubbles,
passed into the opening. The cannula is
now fixed in the vessel by tying the upper
ligature, the low ligature also tied to close
the vein below, and the constricting band
round the arm removed. The saline solu-
tion receptacle should be at such an alti-
tude, usually about three feet, above the
vein that the solution will run in but
slowly. The heart and blood-pressure
should be watched, care being taken not
to dilate and weaken the former or to
raise the latter excessively by infusing
too much solution. The usual amount is
1 to 3 pints (500 to 1500 c.c). In shock
injection of 1:1000 epinephrin solution
with a hypodermic syringe into the lumen
of the rubber connecting tube may be ad-
vantageous. This should be done slowly,
a few drops being given every few min-
utes until the desired rise in blood-pres-
sure has been obtained. Another good
procedure is to drop the epinephrin, ac-
cording to requirements, in a funnel into
which the saline solution is being poured
at intervals as it is consumed.
Many users of intravenous saline ther-
apy simplify the insertion of the needle
by dispensing with exposure of the vein,
the needle, with an obtuse angle point,
being merely thrust obliquely into the
distended vessel while the solution is flow-
ing. The point of the needle should not
be too sharp, to avoid inadvertent injury
to the vessel's walls after its insertion,
and should be held firmly in proper rela-
tion to the vein while the saline solution
is being run in.
(4) Intraperitoneal saline infusion
is of value at the termination of
abdominal operations attended with
marked shock, provided extension of
an intra-abdominal infection as a re-
sult is not apprehended. J. G. Clark
found that flushing- the peritoneum
with the solution greatly augmented
leucocytosis, and advocates its use
even in peritoneal infections. He
makes it a practice to leave at least 1
liter of solution in the peritoneal
cavity even after the simplest opera-
tions, not only the circulation, but
also the kidneys, skin, intestines, and
all other organs functionating better
under its influence, thirst being re-
lieved, and the virulence of infection
being decreased.
Contraindications. — Saline infu-
sions are contraindicated in many in-
stances of edema, especially where
there is retention of sodium chloride
in the system as a result of renal im-
pairment, and in pulmonary edema.
Pure salt solution often fails to bring
on diuresis in cholemic states, prob-
ably because of a prejudicial action of
the circulating bile on the kidneys.
Other Solutions. — The studies of
Jacques Loeb have shown that a
solution of pure sodium chloride in
distilled water has poisonous proper-
ties owing to the complete absence of
other salts, especially those of calcium
and potassium. As the tap-water gen-
erally employed in the preparation of
normal saline solution is likely to
contain some calcium salts, but little
of which is required to ofit'set the
poisonous influence of the sodium, no
difficulty from the use of the ordinary
normal saline solution is, as a rule,
experienced. The possibility of dan-
ger from excessive displacement by
sodium chloride of the calcium and
potassium salts known to be essential
to the vitality of the body cells is
recognized, and Thies has advised
against the use of pure normal so-
dium chloride solution, especially in
small children with disorders asso-
ciated with a considerable elimination
of salts, in inanition from pyloric
stenosis or other cause, in cachexia,
200
SPIGELIA.
in conditions entailing changes in the
kidneys or cardiovascular system, and
in febrile affections, in which elimina-
tion of salts other than those of so-
dium is augmented. Thies recom-
mends for rectal introduction a solu-
tion containing 0.6 per cent, of sodium
chloride and 0.02 per cent, each of
calcium chloride and potassium chlo-
ride, and for hypodermoclysis, one
containing 0.85 per cent, of sodium
chloride and 0.03 per cent, each of
the other salts. Among other im-
proved substitutes for normal sodium
chloride solution are : —
Dawson's solution, containing 0.8 per
cent 
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